A SYSTEMATIC APPROACH TO PLANNING FUNCTIONAL TREATMENT SESSIONS Presented by: Mildred Alfonso MS, OT/L malfonso@keiseruniversity.edu 1 1. The Medical Diagnosis Quick Reference Form. Purpose: To provide Occupational therapy intervention guidelines for a specific diagnosis. 2. The client/patient individual circumstances, preferences and assessment findings. Purpose: To ensure client-centered treatment. 3. Treatment Plan Components Treatment Approach o Remediate o Compensate o Both Education requirements HEP/Home Practice Program (HPP) Purpose: To ensure you have covered all aspects of treatment 4. The Treatment Continuum Purpose: To help the therapist analyze a specific occupation and identify where to begin the intervention. 5. Task specific training and occupation-based boxes. Activity Boxes can be used in 2 different ways: o Approach #1: Purpose: The focus can be on remediation of a skill through much repetition with a challenge o Approach #2: The focus can be on the activity itself as the treatment focus Purpose: Increase independence of a specific occupation/activity When appropriate use in place of 97110 or nonfunctional activities NOTE: This lecture will have a focus on increasing UE function. The information can be adapted for other impairments as needed.
2 PART 1: MEDICAL DIAGNOSIS QUICK REFERENCE FORM PURPOSE: Purpose: To provide Occupational therapy intervention guidelines for a specific diagnosis. This will ensure the therapist does what is medically optimal and does not Injure the patient Neglect to provide treatment that should have been provided by OT PRACTICAL TIPS WHEN MAKING YOUR OWN QUICK REFERNCE FORM: 1. Get information from responsible sources (see resource list at the end) 2. Form should be portable 3. Design of form is facility dependent 4. Form should have a guiding statement PART 2. THE PATIENT 1. What are the patient s specific goals and needs? 2. Evaluation What is the patient capable of doing? Consists of: Occupations o ADL, IADL, Rest and Sleep, Education, Work, Play, Leisure, Social Participation (OTPF 3) Assessments o What is hindering or facilitating independence with occupations. o Assessments with focus on UE function (Lang & Birkenmeier, 2014) Performance Measures Action Research Arm Test (ARAT): 19-item assessment with 4 subscales o Grasp, Grip, Pinch and Gross Motor Movement 10-15 minutes to complete Box and Blocks measures unilateral UE dexterity o 5 minutes to complete Self-report measures Motor Activity Log o 15-20 minutes to complete Stroke Impact Scale - 5 minutes per domain (10 domains) LTGs Goals should be set to function not impairment o Match goals to assessment results o Client-centered use measures such as the COPM or similar tool Using the LTGs and the capabilities and interests of your patient you then proceed to plan out their treatment.
3 PART 3: TREATMENT PLAN COMPONENTS When designing a comprehensive treatment plan consider all areas including: What approach am I taking? o Remediate fix an impairment o Compensate find a way to do the occupation now (e.g., equipment, method) o Combination of both Education/Training What specific methods will we use to educate the patient and caregivers? o What specific topics/techniques should the patient/caregiver receive education/training in? o What methods will be used Handout, video, 1:1 instruction, class, etc. o How will learning be measured and documented? Practice Program - What specific methods will we use to issue a HEP/Home Practice Program (HPP)? o Is the handout at a level the patient/caregiver can understand (health literacy)? o Record repetitions/sets using an Activity Log o Record session so the patient/caregiver can use it for future reference. PART 4: TREATMENT CONTINUUM Two Approaches: Top down start with occupations Bottom up start with impairments/client factors This worksheet is used when you know the occupation you want to address but you are not sure where in the continuum to start. See worksheet at end of this packet.
4 PART 5: ACTIVITY BOXES The activity boxes should not just be a box where you store supplies for an ADL or IADL it is how you use the box that makes it functional. Activity Boxes can be used in 2 different ways: Approach #1: The focus can be on remediation of an UE skill through much repetition with a challenge and/or Approach #2: The focus can be on the activity itself as the treatment focus which may have an educational perceptual, or cognitive component such as problem solving or memory and may have a compensatory component. APPROACH #1: USING ACTIVITY BOXES FOR TASK-BASED TRAINING The patient must participate in behavioral experiences that directly replicate the sensorimotor demands that need to be acted on to execute the motor skill successfully. (Lang & Birkenmeier, 2014) The premise for task-based learning is that if a patient is to learn a specific skill then they must train for that skill. Some skills may generalize but with shorter lengths of stay we need to specifically target what the patient needs. In the above statement the word practice is used instead of the word train because it implies that it involves the ongoing challenge of a person s capabilities. (Lang & Birkenmeier, 2014) The main focus of this training is on UE movements which can be broken down into 4 components: 1. Reach 2. Grasp 3. Manipulate 4. Release (as cited in Lang & Birkenmeier, 2014) General: The activity box is used to focus on an impairment and remediate it. Items in the box will provide challenging, repetitive practice with the goal of remediating the impairment. o For example: the patient has difficulty with the fine motor and grasp strength involved in medication management. The medication box will provide the items needed to: Improve grasp - repetitive practice of handling, opening and closing containers Improve fine motor skills - small items which will resemble pills in order to practice picking them up, and placing them into pill organizers Bilateral hand use Gross motor have the patient place the pill bottles on a shelf
5 TASK-SPECIFIC TRAINING PRINCIPLES 1. Task-specific training should be relevant to the patient. The therapist should use meaningful activities o Can use assessments like the COPM to find out what is important to the patient. Task should be real world or context specific o Treatment environment should reflect the home and/or community enviornment (enriching the enviornment). The tasks should be functional 2. Task-specific training practice sequence should be randomly ordered. Repetition with variation o Task variability is important to increasing generalization of learning to new tasks (Krakauer, 2006) o Use different contexts, setting, occupational demands and sequences (Bayona, Bitensky, Salter & Teasell, 2005) 3. Task-specific training should be repetitive Preferably involve massed practice o There must be sufficient repetitions to cause changes in the brain Assign the patient practice outside of therapy (practice in their room, HEP/HPP) Requires sufficient repetitions to improve cortical reorganization 4. Task-specific training should aim towards reconstruction of the whole task Use the treatment continuum to achieve greater occupational independence When remediating begin with skill acquisition and massed practice of the individual component parts However, must be sure to end with the entire occupation being practiced 5. Task-specific training should be positively reinforced Feedback should be timely and positive decreasing over time to prevent dependency 6. Task-specific training should be challenging (Hubbard, Parsons, Neilson and Carey, 2009)
6 How do you start Task-based Training? - Using the LTGs and the capabilities and interests of your patient you match and appropriately grade the task-specific activity to your patient. 1. Identify the LTG goal you are addressing. Example: after completing the COPM the patient has identified that she has difficulty opening up medication bottles and handling the pills. 2. Analyze your assessment findings to identify the impairments that are interfering with opening containers and handling pills. Example: Findings of the ARAT - her grasp is weak, and she had decreased fine motor skills 3. Select a task that would target the impairments above. Example: You have selected the Medication Box. The focus of this box is to manipulate various medication bottles, medication pill organization containers and items the size of pills (e.g., beads). o The objective is to provide sufficient repetition and challenge to facilitate cortical changes. 4. Grade the task up or down as needed to provide the just right challenge to the patient. Example: If the size of the beads are too difficult for the patient use larger beads. 5. Incorporate into your task practice the various UE movement components that are used for: Gross motor Fine motor and Bimanual hand use 6. Provide a total of 2-3 different complementary tasks in a session for the patient to complete. Example: use the following additional box Fastener Box, Nuts and Bolts Box, Handling Money Box (coins) (Lang & Birkenmeier, 2014)
7 APPROACH #2: USING ACTIVITY BOXES FOR TREATMENT-BASED TRAINING General: The activity box is used to enhance the treatment session by providing occupation-based media. The focus is on educating the patient or on helping the patient gain necessary skills needed to complete an occupation. Items in the box will provide items the therapist can use to instruct/train/practice an occupational activity o For example: If the patient has difficulty managing their medications the therapist can use the contents of the box to teach compensatory techniques such as making a schedule, or using electronic reminders to take medication. The same Medication Activity Box can be used for either approach 1 or 2 however you will use the kit differently in each approach.
8 References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. Bayona, N.A., Bitensky, J., Salter, K. & Teasell, R. (2005). The role of task-specific training in rehabilitation therapies. Top Stroke Rehabilitation, 12(3), 58-65. Hubbard, I.J., Parsons, M.W., Neilson, C., & Carey, L.M. (2009). Task-specific training: evidence for and translation to clinical practice. Occupational Therapy International, 16(3-4), 175-189. Krakauer, J.W. (2006). Motor learning: its relevance to stroke recovery and neurorehabilitation. Current Opinion in Neurology, 19, 84-90. Lang, C.E., & Birkenmeier, R.L., (2014). Upper-extremity task-specific training after stroke or disability: A manual for occupational therapy and physical therapy. Bethesda, MD: AOTA.
9 RESOURCES Quick-Reference Diagnosis Form Get information from responsible sources AOTA Guidelines - https://myaota.aota.org/shop_aota/ Comprehensive Textbooks o Occupational Therapy for Physical Dysfunction by Radomski and Trombly o Pedretti s Occupational Therapy: Practice Skills for Physical Dysfunction Definitive books on the topics o Stroke Rehabilitation a Function-Base Approach by Glenn Gillen Journal articles Government sources o VA/Do Clinical Practice Guidelines https://www.healthquality.va.gov/guidelines/rehab/stroke/ o National Institute of Health - https://www.nhlbi.nih.gov/health-pro Interview Tool Occupational Profile from AOTA https://www.aota.org/practice/manage/reimb/occupational-profile-document-valueot.aspx?promo_name=reimbersement&promo_creative=practice&promo_position=latest-news Canadian Occupational Performance Measure (COPM) - http://www.thecopm.ca/learn/ Assessments UE Grasp, Grip, Pinch and Gross Motor Movement http://www.strokecenter.org/wp-content/uploads/2011/08/action_research_arm_test.pdf Box and Blocks measures unilateral UE dexterity http://www.rehabmeasures.org/pdf%20library/box%20and%20blocks%20test%20instructions.pdf Motor Activity Log - https://www.uab.edu/citherapy/images/pdf_files/cit_training_mal_manual.pdf Stroke Impact Scale - https://www.strokengine.ca/pdf/sis.pdf Task-Based Training The Manual Upper-Extremity Task-Specific Training After Stroke or Disability: A Manual for Occupational and Physical Therapy by Lang and Birkenmeier, 2014 Activity Boxes Occupation based kit ideas for your rehab department https://www.seniorsflourish.com/occupationbasedkits/ https://www.seniorsflourish.com/treatmentideasformen/ and Occupation-based intervention in medical-based settings. (Article from OT Practice) http://commons.pacificu.edu/cgi/viewcontent.cgi?article=1014&context=otfac Occupation-based treatment kit ideas for FW projects. http://health.utah.edu/occupational-recreational-therapies/docs/fieldwork/occupationbasedkits.pdf Occupation-based kits for sale http://functionaltherapyactivities.com/fca%20web_026.htm
OCCUPATIONAL THERAPY TREATMENT CONTINUUM 10 OCCUPATIONS - ADL, IADL, Work, Education etc. Q - What occupation did the client have difficulty completing independently? ACTIVITIES (Purposeful activity part of the actual occupation) Q - What part of the occupation does the client have difficulty with or prevents independence? PREPARATORY TASKS (Remediation) Q - What underlying deficit interferes with completion of the task that can be improved? PREPARATORY METHODS Q - Is there a modality, splint, AT, device or technique needed to prepare the patient for occupational performance? Example: Brushing his teeth Example: Opening toothpaste and putting it on toothbrush Example: The patient has stiffness and weakness in his fingers/hand and therefore cannot generate enough force to turn the cap and squeeze the tube. Example: Patient has stiff hands which make it more difficult to complete activities. OT/OTA Decision: 1. Do I keep him occupation-based and have him keep practicing brushing his teeth (whole occupation)? OR 2. Should he practice a specific step? If he needs to practice a specific step grade down to activities and practice the step he is having difficulty with. OT/OTA Decision: 1. Do I have him practice this step repeatedly? AND/OR 2. Compensate give him another way of doing it which may require an adaptation (toothpaste with a flip top). AND/OR 3. Do I remediate (fix something) decrease the impairment (coordination, strength, etc.) by focusing on it. If yes grade down to Remediation OT/OTA Decision: 1. What exercises/activities can I include in his treatment to strengthen and decrease the stiffness in his fingers/hand so he can turn the cap and squeeze the tube and place toothpaste on toothbrush? AND 2. Do I need any preparatory methods prior to working on remediation? If yes go to Preparatory Methods. Is there a functional activity the client needs or wants to do in place of or in addition to exercise? Difference between using 97110 Ther ex (least recommended) 97530 Ther activity 97535 Self care OT/OTA Decision: What can I do to prepare the patient for using his hands? Possible answer: hot pack, paraffin Fluidotherapy, self ROM, etc.
Mildred Alfonso MS, OT/L, FOTA Conference 2017 11 CLIENT: OCCUPATIONS - ADL, IADL, Work, Education etc. Client displayed difficulty with: ACTIVITIES (Purposeful activity part of the actual occupation) What part of the task does the client have difficulty with? PREPARATORY TASKS (Remediation) What underlying deficit interferes with completion of the task that can be improved? PREPARATORY METHODS Is there a modality, splint, AT, device or technique needed to prepare the patient for occupational performance? Mildred Alfonso MS, OT/L, FOTA Conference 2017