OTA II

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OTA II

• Physical Dysfunction and Activities of Daily
  Living Assessment, Analysis and Intervention

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Class Outline

• Defining Physical Dysfunction
• Causes of physical dysfunction
• Arthritic Diseases
• Hip/Knee Replacements
• Cardiopulmonary Diseases
• Lab Activity

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Physical Dysfunction

• What is physical dysfunction?
• Related to function of body structures
• Strength
• Muscle strength related to ability to perform
  Occupations and ADLs
• Range of Motion
• Ability to use all joints, or necessary joints
  for functional movement
• Endurance
• Ability to sustain movement over time, to enable
  performance of functional activity

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Causes of Physical Dysfunction

• Congenital
• Present at birth
• Examples Cerebral Palsy, Muscular Dystrophy
• Acquired
• Disease
• Examples Rheumatoid arthritis, heart disease
• Accidental
• Examples Hip fracture, spinal cord injury

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Arthritic Diseases

• Osteoarthritis
• Degenerative Joint Disease
• Breakdown of cartilage in the joints
• Rheumatoid Arthritis
• Chronic, systemic autoimmune disorder
• Immune system attacks the body
• Leads to breakdown of joints and calcification
• Gout
• Metabolic disease marked by urate
• Causes acute recurrent episodes of arthritis

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Osteoarthritis
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Rheumatoid Arthritis
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Common Hand Deformities

• Crepitation Grating, crunching or popping
  sensation/sound in the joints (OA RA)
• OsteoArthritis Osteophyte formation (Bony spur
  that forms along a joint)
• Bouchards Nodes (PIP joint)
• Heberdens nodes (DIP joint)

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Common Hand Deformities Rheumatoid Arthritis

• Fusiform Swelling
• Swan Neck

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Common Hand Deformities Rheumatoid Arthritis

• Boutonniere Deformity
• Trigger Finger

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Rheumatoid Arthritis Common Hand Deformities

• Ulnar Drift

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Rheumatoid Arthritis Common Hand Deformities

• Thumb Deformities (Figure 30-9, pg. 566)
• IP hyperextension, MPC flexion (most common)
• IP hyperextension, MPC flexion, carpometacarpal
  subluxation
• IP flexion, MPC hyperextention, carpometacarpal
  subluxation

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Treatment Objectives

• General objectives might include
• Maintain or increase joint mobility and strength
• Increase physical endurance
• Prevent, correct or minimize the effect of
  deformities
• Maintain or increase ability to perform ADLs
• Increase knowledge about the disease and the best
  methods of dealing with the physical,
  psychological and functional effects
• Assist with stress management and adjustment to
  physical disability.

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Treatment Methods

• Medical Management
• Drug Therapy
• Surgical
• Rest
• Positioning (to prevent contractures)
• Physical Agent Modalities
• Therapeutic Activity and Exercise (ROM exercises
  pg. 579
• Splinting pg. 573 Early
• support the joint in an optimal position for
  function and to reduce inflammation by providing
  rest and support to the joint
• Energy Conservation (See principles of energy
  conservation pg. 575)
• Assistive Devices (See Assistive Devices Table
  pg. 577)
• Joint Protection
• Respect pain
• Maintain muscle strength and joint ROM
• Avoid positions that put stress on involved joints

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Hip and Knee Replacements

• Weight Bearing Restrictions
• NWB (Non-weight bearing)
• TTWB (Toe-touch weight bearing)
• PWB (Partial weight bearing)
• WBAT (Weight bearing as tolerated)
• FWB (Full weight bearing)
• Hip Replacement Precautions
• See handout

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In Class Activity

• Consider activity limitations with hip and knee
  replacements
• Dont forget precautions!
• Activity Limitations
• Dressing
• Mobility (sit to stand transfers, driving)
• Bathing and Toileting
• Meal Prep and Housekeeping

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Cardiac Diseases

• Cardio-Obstructive Pulmonary Disease
• Angina
• Heart Attack (Myocardial Infarction)
• Congestive Heart Failure

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Cardiac Rehabilitation

• Acute, inpatient rehabilitation consists of
• monitored ADLs
• instruction in cardiac and postsurgical
  precautions
• energy conservation
• graded activity
• risk factor management
• discharge activities
• Tools for measuring a clients response to
  activity are used to evaluate the cardiovascular
  systems response to work. Going beyond the
  physician recommended maximums can put the client
  at risk.

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Typical Cardio Measures

• Heart Rate
• Measured in Beats per minute
• Heart rate should rise in response to activity
  but moderate activity should not result in
  maximal heart rate (could indicate need to grade
  the activity to conserve energy)
• Blood Pressure
• Pressure the blood exerts against the artery
  walls as the heart beats.
• Rate Pressure Product
• Rise at peak return to baseline in recovery
• RPP HR(beats/min) x SystolicBP
• 100

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OT Evaluation of Persons with Cardiopulmonary
Dysfunction

• Review of Medical Record (Look For)
• Diagnosis
• Severity
• Associated Conditions
• Secondary Diagnoses
• Social History
• Test Results
• Precautions

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OT Evaluation of Persons with Cardiopulmonary
Dysfunction

• Client Interview
• Clients with a history of angina should be asked
  to describe in terms of intensity of episodes,
  and if theyve had a MI can they differentiate
  between the symptoms
• Identify activities that bring shortness of
  breath
• Look For
• Signs of Anxiety
• Shortness of Breath
• Confusion
• Difficulty comprehending
• Fatigue
• Posture
• Endurance
• Ability to Move
• Family Dynamics

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OT Evaluation of Persons with Cardiopulmonary
Dysfunction

• Clinical Assessment
• Determine clients present functional ability and
  limitations
• Monitored for heart rate, BP and signs/symptoms
  of cardiac/respiratory distress during an
  evaluation of tolerance to postural changes, and
  a functional task
• See Early pg. 669 table 35-2 and 673 table 35-3
• Range of Motion, Strength and sensation may be
  assessed.
• Clients cognitive and psychosocial status will
  become apparent through interview and
  observation.
• Formal assessments only used if concerns arise

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OT Treatment of Persons with Cardiopulmonary
Dysfunction

• Guided by present clinical status, recent
  functional history, response to current activity,
  and prognosis
• Energy costs of an activity and the factors that
  influence them can further guide the OTA in safe
  progression of activity (Oxygen consumption often
  used)
• Resting quietly in a bed requires the least
  amount of oxygen per kilogram of body weight
• 1basal metabolic equivalent (MET) OR
• 3.5ml of Oxygen/kilogram body weight

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OT Treatment of Persons with Cardiopulmonary
Dysfunction

• As activity increases more oxygen is required to
  meet the demands of the task
• See pg. 674 table 35-4 for MET values associated
  with self-care and homemaking tasks
• As a general rule, once clients tolerate an
  activity (ex. Seated sponge bathing) with
  appropriate responses, they can progress to the
  next higher MET level activity (ex. Standing
  sponge bath)
• Duration of activity must be considered when
  determining activity guidelines

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OT Treatment of Persons with Cardiopulmonary
Dysfunction

• A person with difficulty performing a 2 MET
  activity must still use a commode (3.5METS) or
  bedpan (5METS) for their bowel management. A
  person can perform at a higher than usual MET
  level for brief periods without adverse effects.

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OT Treatment of Persons with Cardiopulmonary
Dysfunction

• Diaphragmatic breathing
• Benefits some clients
• Breathing patternt hat calls for increased use of
  the diaphragm to improve chest volume
• Clients can learn this technique by placing a
  small paperback novel on the abdomen just below
  the thorax. The client lies supine and is
  instructed to inhale slowly and make the book
  rise. Exhalation through pursed lips should cause
  the book to fall.

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OT Treatment of Persons with Cardiopulmonary
Dysfunction

• Relaxation
• Progressive muscle relaxation in conjunction with
  breathing exercises can be effective in
  decreasing anxiety and in controlling shortness
  of breath.
• One technique involves tensing the muscle groups
  while slowly inhaling, followed by relaxation of
  the muscle groups when exhaling twice as slowly
  through pursed lips.
• It is helpful to teach the client a sequence of
  muscle groups to tense and relax. One common
  sequence involves
• Tensing and relaxing the face
• Followed by the face and neck
• Next the face, neck and shoulders
• Etc.
• Until you reach the toes
• A calm, quiet and comfortable environment is
  important for learning.

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OT Treatment of Persons with Cardiopulmonary
Dysfunction

• Energy Conservation
• Can help clients perform at a higher funcitonal
  level without expending more energy.
• Based on knowledge of how specific factors
  increase the bodys workload
• 6 variables that increase oxygen demands
• Increased work rate or activity pace
• Increased resistance
• Increase use of large muscles
• Increased involvement of trunk musculature
• Raising the arms
• Isometric work (straining)
• Arm activity has also been shown to require a
  greater cardiovascular output than lower
  extremity activity
• Standing activities require more energy then
  seated activities.

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OT Treatment of Persons with Cardiopulmonary
Dysfunction

• Energy Conservation Contd
• Extremes of temperature, high humidity, and
  pollution make the heart work harder
• Exhaling with exertion is more energy efficient
  and helps control the rate of increase of
  systolic blood pressure with activity.
• By applying all this information, suggestions can
  be made for modifying an activity that will
  decrease the amount of energy required for the
  task.
• Should be client centred
• Use of time management important

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Client and Family Education

• Must be taught and reinforced to the client and
  family members by the team
• Pulmonary anatomy
• Disease process
• Symptom management
• Risk factors
• Diet
• Exercise
• Energy conservation
• Including family members provides support
  indirectly to the client through the family unit.
  Such support is critical when a client is
  dependent on the help of a family member to
  accomplish everyday tasks.

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Lab Activity

• For the following activities think of 3 means of
  conserving energy, considering that you have a
  client with cardiac and pulmonary difficulties
• Making vegetable soup
• Planting a flower garden/vegetable garden
• Washing, drying and styling their hair
• Starting an independent fitness program
• Getting groceries
• Cleaning a bathroom
• Please explain your choices for each one and hand
  this in as your lab mark for this week.

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Lab Case Study

• 62 year old woman
• Cardio-Obstructive Pulmonary Disease
• Lives with her husband
• Three children live in the community
• Works as a cleaner in an industrial site