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OPTIMIZE RECOVERY WITH HOME PROGRAMS & UP-LEVEL YOUR OT PRACTICE

HOME EXERCISE PROGRAMS

Occupational therapists often recommend and establish home exercise programs when clients are ready for discharge. Is this the best time or even the right time? I don’t think so and I’ll tell you why....

People need time and practice to learn and build habits. This is especially true of occupational therapy (OT) clients experiencing interruptions in health. People in the midst of a health crisis or concern are not functioning at their best. They are often in pain and worried; many do not understand their conditions and some experience cognitive deficits. Caregivers often do not understand the medical system and have other life events happening simultaneously. That’s a LOT!

Consider the amount of practice and memorization required when you want to learn something new - when you’re feeling good and have a level of knowledge about a topic. As healthcare providers we must incorporate our skills in ways that support client success. Practice models that empower clients to take responsibility for their health are needed now more than ever and are super simple to implement. Establishing home programs at the start of care provides more learning and practice opportunities for clients while you’re available to guide and support them.

Support during challenging times can put your clients’ minds at ease, allow you to build the appropriate home program and give you the chance to see what they’re capable of. This gives them time to heal, learn and progress. Additionally, starting a home program right away provides opportunities for repetition (a key learning ingredient) and facilitates habit building (an OT superpower) that may translate into a routine once they’re home. Routine is key for follow through, successful recovery and future health.

HOME PROGRAM vs. HOME EXERCISE PROGRAM

Eliminate the word “exercise” and you’ve got an entirely new and more versatile approach! Occupational therapy practice brings so much more to the table than exercise. Essentially, OT’s should only use exercise if our clients value it as an occupation – unless recovering motor skills following stroke and even then it depends on client ability. Otherwise, we can and should use our other, OT specific, super-powers. Energy conservation techniques are one excellent example of a perfect home program. Point to Ponder: What are some other strategies we use in occupational therapy that should be used as home programs?

HOME PROGRAMS & PRACTICE UP-LEVEL

Establishing appropriate home programs should be done immediately as part of a skilled OT plan of care (not when it’s time for discharge so you can check of a care path box). Not only will this increase your practice value, but it will also drive client success. NOTE: If you don't currently establish home programs immediately upon start of care, that’s ok. It’s not too late to begin. We are always learning new ways to do things to create positive change in our practices. Read on to learn more about how to get started.

ESTABLISHING A HOME PROGRAM

It is understood that OT practitioners incorporate proper clinical reasoning skills when establishing any and all programs whether they are skilled, maintenance, habilitative or rehabilitative. If you are a client or caregiver, referring to this information can help you identify if your provider is meeting this need for you.

Some OT skills used through proper set up of home programs include:

  • Diagnosis knowledge

  • Skilled intervention techniques

  • Environmental supports, barriers, modifications

  • Caregiver supports & training

  • Task analysis & grading

  • Task modification strategies

  • Clinical reasoning

Here is a simple, 5-step process for establishing a home program that OT practitioners can use now:

STEP 1 – IDENTIFY NEED: With the understanding that a client will continue to benefit from the program after discharge from skilled OT, select your topic. Examples include diaphragmatic breathing for a person with COPD or mirror therapy for a stroke survivor. NOTE: the home program must be safe for the client and/or caregiver to complete on their own.

STEP 2- CREATE PROGRAM: Create the home program with the client's input. Gather appropriate materials to support client education and training. Your program should include a variety of media. Examples include visual images such as pictures and videos, required equipment and tracking forms along with your skills. HELPFUL HINT: video technology is a simple and effective way to provide educational content that supports client learning. It’s time to start using modern technology in OT practice, don’t you think?

Did you know...

“...the narrative presentation of educational information is possibly not always the best choice. Video-assisted patient education can also be effective when a model patient demonstrates the best practice. This assumption is supported by Bandura’s ‘Social Cognitive Theory’, which places observational learning at the center of behavioral modelling [30]....”(Abed, Himmel, Vormefeld & Koschak, 2014).

STEP 3 – EDUCATE & TRAIN: Begin educating the client on the program. Education can and should include the purpose and benefits; proper activity completion and self- monitoring; your skilled demonstrations and input. You should also ask for client feedback. The goal is to lead the client towards independent completion. If the client will not be independent upon discharge, caregiver training may be appropriate.

STEP 4 – FOLLOW UP: Follow up with the client during your skilled time together to determine progress. You may:

  • Ask for feedbackabout how the home program is going.

  • Have the client demonstratewhat they've been doing.

  • Provide your skilled feedback and input, demonstrating or encouraging performance modifications as necessary. Do this until the client (or caregiver) is competent. At this point, your skill is no longer required and the client should continue on their own.

STEP 5 – GRADUATE TO INDEPENDENT: Be sure to incorporate strategies that can be used when improvement occurs (grade up) or if they are having a bad day (grade down). Remember...Once they or the caregiver demonstrate independence and feel confident, you no longer need to address this during your skilled sessions. If the client remains on a skilled OT program with you, establish regular check-in periods until therapy is discontinued. If you are a private clinic owner, consider establishing a regular check-in protocol – this can contribute to continued improvement for clients with chronic conditions while allowing you to maintain rapport – a key ingredient for them selecting you should they have any future therapy needs.

SUMMARY

That’s all there is to it. This simple strategy will no doubt change your clients’ views of occupational therapy and their time with you. Taking ownership of one’s health requires time, especially when behavioral change is involved. OT’s have the skills to empower clients to continue towards better health and improvement beyond their time on a skilled OT program. A multitude of benefits will occur from making this one simple shift in practice – outcomes will improve for all - clients, caregivers, clinic owners and the profession. Are you willing to give it a try?

Reference:

Abed, M., Himmel, W., Vormfeld, S., & Koschak, J. (2014). Video assisted patient education to modify behavior: A systematic review. Patient education and counseling, 97(1), 16–22. https://doi.org/10.1016/j.pec.2014.06.015

MIRROR THERAPY: AN EFFECTIVE INTERVENTION FOR TREATING NEUROLOGICAL DEFICITS FOLLOWING STROKE

Mirror Therapy, also known as Mirror Visual Feedback, is an evidence-based treatment approach that can be used with people who experience brain injuries such as cerebrovascular accident (CVA)/stroke or TBI. To understand what mirror therapy is and how it works, this article reviews common deficits that occur following stroke and brain injury along with various aspects of the brain and how each relates to function before explaining how mirror therapy works and why it should be a first choice intervention for Occupational Therapy Practitioners and the survivor.

QUICK STATS

Just so we know why this conversation is important, let’s get an idea of how prevalent CVA and TBI are. According to the CDC (2021), more than 795,000 people in the U.S. experience a stroke each year. It is the 3rd leading cause of death and is the leading cause of disability in the United States. World wide, 15 million people have strokes every year (Strokestatistics.org). It is also important to note that traumatic brain injuries are responsible for about 2.87 million emergency room visits, hospitalizations and deaths (CDC, 2019).

BRAIN INJURY DEFICITS

Brain injuries cause physiological changes within the brain that affect the body. Changes in any bodily area can result in deficits that negatively impact a person’s life. Here is a list of common changes that occur following stroke and brain injury. Often times, a person experiences more than one.

Arms/Legs/Trunk

  • Hemiparesis/paralysis

  • Muscle tone changes – High/Low/Flaccid/Fluctuating

  • Impaired sensation – Light touch/Deep pressure, Hot/Cold, Proprioception, Kinesthesia

  • Decreased Active/Passive Range of Motion

  • Decreased strength

  • Decreased speed and/or accuracy of movement

  • Decreased dexterity

Vision

  • Blurred vision

  • Double vision

  • Visual field cuts (hemianopsia/hemianopia is one of the most common)

Perception

  • Hemi-inattention/Neglect (Decreased/Absent awareness of one side of the body and environment)

Cognition

  • Decreased ability to perform executive functions (higher level cognitive processes)

  • Decreased insight

  • Decreased judgment

You can imagine how difficult it can be to navigate through life when a body changes in these ways. Life changes not only for the person with the injury, but also for those whom they love. We can view it as a family affair.

THE BRAIN AND FUNCTION

While the human brain might be considered small in comparison to the entire body, it is often thought of as the control center for everything we do. This mighty organ is very busy! Since we are talking about brain injuries, it is worthwhile to discover some of the ways the brain works. Here I review some key brain areas so you can understand how or why your body works the way it does.

  • The Frontal Lobe is home to areas involved with executive functions (those higher level cognitive skills necessary for living an independent life) and movement. Important areas associated with movement include the primary motor cortex (responsible for movement on the opposite/contralateral side of the body), the premotor cortex (responsible for movement observation) and the supplementary motor area (responsible for bimanual coordination).


  • The Posterior Parietal Cortex plays a role in planning movement.

  • The Cerebellum is positioned beneath the temporal and occipital lobes and plays keys roles in balance, coordination, executive functions and personality.

All of these areas plus more all work in harmony to produce meaningful thought processes and controlled movement.

Functional Magnetic Resonance Imaging (fMRI) makes it possible to see brain activity, demonstrating to researchers that there is activity in the brain before movement occurs when a person engages in object directed movement – picking up a bottle of water, for example. This brain activity occurs when a person is planning to pick up the bottle or visualizing picking up the bottle. This is important to understand because humans use the arms and hands in most tasks throughout the day. Arms and hands are used when engaging in Basic Activities of Daily Living (B-ADL) such as ambulating/transferring, bathing, toileting hygiene and dressing, as well as Instrumental Activities of Daily Living I-ADL) to include meal prep and driving/community mobility. The brain is very active before movement. Because of research such as this that shows brain activity during thought and planning, envisioned movement is considered a viable rehabilitation strategy.

MIRROR THERAPY

Visual Illusion & Brain Re-organization

Mirror therapy creates a visual illusion when a person moves a NON-AFFECTED limb in front of a mirror. Watching the reflection in the mirror tricks the brain into believing the AFFECTED limb is moving normally. Many changes occur inside the brain when engaging in activities in front of the mirror. Overall, the brain is re-organized as multiple dormant areas are activated and over-active areas are suppressed. This happens both ipsilaterally and contralaterally, ultimately facilitating improved communication between both hemispheres.

Mirror Neurons

Mirror neurons are located in the pre-motor cortex, inferior parietal lobule and spinal cord. Those within the pre-motor cortex and inferior parietal lobule are stimulated with observation, imagination or performance of a motor act. They are responsible for goal directed, organization of movement. Mirror neurons assist with re-organizing a damaged brain and enhance motor control.

When a person passively observes the image moving in the mirror, the mirror neuron system in the cerebral cortex and spinal cord are activated. The passive observation of the normal limb moving in the mirror activates the primary motor cortex of the AFFECTED limb, which can trigger movement.

Possibilities

Using a mirror in this way can cause many positive changes to occur in the brain. When the brain changes, the body can also change. There are possibilities for improving range of motion, strength, movement speed/control and dexterity. Additionally, as the brain re-organizes itself, cognition and attention can also get better. Lastly, because the survivor must look in the mirror (towards the affected side) when engaging in a mirror therapy program, the affected side is acknowledged. This may also help improve hemi-inattention/neglect.

SUMMARY

Mirror therapy is an appropriate intervention for occupational therapy practitioners to use with clients who have experienced a stroke or traumatic brain injury. With proper training and education, mirror therapy is safe for survivors to use during therapy down time or as a home program. People with cognitive deficits and/or hemi-inattention/neglect may require supervision to safely engage in a mirror therapy program. Caregivers can be taught how to use it and may find meaning in helping a loved one with this intervention.

Occupational therapy practitioners understand how habits and routines impact a person’s life and may use this knowledge to integrate mirror therapy into a successful home program. Stroke and TBI recovery can be a long and arduous journey. Using science-backed interventions that demonstrate efficacy, such as mirror therapy, can be built into a routine that promotes improvement leading to greater levels of independence and quality of life for both the survivor and loved ones.


OCCUPATIONAL THERAPY - WHAT IS IT?

OCCUPATIONAL THERAPY: WHAT IS IT ANY WAY?

Despite the fact that the profession of occupational therapy (OT) has been around for 100 years, it remains mysterious to many. Unless you or someone you know has benefited from OT services, chances are good that you are among those who think occupational therapy practitioners help people get jobs. Through this series of blog posts, I hope to demystify the profession and bring clarity about what it is that occupational therapy practitioners actually do.

OCCUPATIONAL THERAPY DEFINED

The Occupational Therapy Practice Framework: Domain & Process, 3rd ed. defines occupational therapy as “...the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings.”

What does all of that mean? Very simply put, occupational therapy practitioners focus on helping people do what they want and need to do every day. The signature of occupational therapy is that we use these everyday activities as a therapeutic means as well as an end. Mary Reilly, one of the most influential people in the field of occupational therapy, described it best in her famous quote, “Man, through the use of his hands, as they are energized by mind and will, can influence the state of his own health.” If you have a moment, allow these words to marinate in your mind. Have you ever found yourself lost in a task not noticing that hours passed by? This can have a very healing effect, even for those who are healthy. Imagine finding that something for someone who is experiencing a challenge in life...imagine helping someone find some peace, comfort or joy and the healing effect that can have.

While ultimately it is the patient or client who must engage in the therapeutic process for well-being to occur, there are times when people need direction. Occupational therapy practitioners can help.

OCCUPATIONS – NO, WE AREN’T GOING TO HELP YOU GET A JOB

I can’t tell you the number of times someone has told me they can’t work or they’re beyond the days of employment so they won’t need to see me. I agree that the terms “occupational therapy” and “occupation” can be deceptive, so let’s begin here. The word occupation, chosen many years ago, is used to describe the tasks we do everyday. Occupations are broken down into categories:

  1. Activities of Daily Living (ADL’s) – ADL’s are tasks we engage in daily such as bathing, dressing and feeding.

  2. Instrumental Activities of Daily Living (I-ADL’s) – more complex than basic ADL’s, I-ADL’s are tasks that support us in daily life. Some examples are taking care of others, driving and community mobility, and financial management

  3. Rest and Sleep – proper rest is essential for healthy participation in other occupations.

  4. Education – activities for learning and participating in formal and informal educational settings

  5. Work – regular engagement in activities for financial or other reward

  6. Play – activities people engage in for fun

  7. Leisure – activities we do just because we want to

  8. Social Participation – activities done with others

Life can be difficult for someone experiencing a struggle in any of these areas. An occupational therapy practitioner, like a detective, is specially trained in how to decipher where a breakdown may be occurring; then, works with a client or patient to find solutions to help ease or eliminate the problem.

CLIENT FACTORS – THE WHOLE PERSON

As an occupational therapy practitioner, I’ve often been able to garner information about a person that others were surprised to learn. I think this is in part because our training includes “Therapeutic Use of Self,” but also because we understand the importance of the aspects of the person themselves and how they influence participation. These Client Factors include values, beliefs and spirituality, body functions, and body structures. Knowing what drives a person and understanding how to use those aspects of a person is important for connecting interventions with meaning and, thus, optimizing the chances of client engagement, carryover, and goal achievement – all part of successful and positive outcomes. Body functions and structures are just as they sound – essentially the physiological and anatomical aspects of a person.

PERFORMANCE SKILLS – TAKING ACTION

Performance skills are divided into three categories – Motor Skills, which consist of movements a person makes as she or he interacts with objects and the environment; Process Skills, which necessitate cognitive abilities for successful execution of daily tasks; and Social Interaction Skills that are seen when interacting with others. “Performance skills are observable elements of action that have an implicit functional purpose; skills are considered a classification of actions, encompassing multiple capacities (body functions and body structures) and, when combined, underlie the ability to participate in desired occupations and activities.” (AOTA, 2014). Sound understanding of Client Factors and Performance skills along with knowledge of the level of function within each patient plays a key role in how occupational therapy practitioners design needed interventions.

THE POWER OF PATTERN – KEEP IT SUPER SIMPLE

Habits, routines, rituals and roles drive human behavior, allowing us to easily move about our lives. Taking time to think about completing each task we engage in would leave us mentally exhausted AND cause our lives to slow waaaay down. There is a level of power in using these behaviors, but there is also a line to consider between supportive and destructive patterns. The habit of engaging in a routine of starting the day with a delicious cup of coffee or a favorite workout can keep someone on track for a smooth day. Routines are multiple and vary depending on the role one is carrying out at the time. A woman in her late twenties may have the role of employee, wife, mother, daughter, sister, etc. Her morning routine as an employee and mother may include several habits – drinking a bottle of water upon awakening, kissing her children when dropping them off at day care and then going through the Starbuck’s drive through for coffee. Drinking her coffee in silence while driving may be a ritual she enjoys on her commute to work. Occupational therapy practitioners understand the importance of these Performance Patterns and how they can support or hinder an individual’s ability to independently engage in occupations.

KEEPING IT ALL IN CONTEXT - MR. SMITH, IN THE BEDROOM, WITH A PAIR OF PANTS

Similar to a game of Clue, the context and environment where one engages in daily activities are key factors to consider. Everything we do is done somewhere within some situation. In order to help an individual achieve maximum independence, it is essential to understand this information. For example, a person who gets dressed in the bedroom (environment), in the morning (temporal/time), after showering (temporal/time) while getting ready for work (context) is very different from someone who stays in their night clothes most of the day.

PUTTING THE PIECES TOGETHER – IT ISN’T AS PUZZLING AS IT SOUNDS

If you like puzzles, you know how satisfying it is to put in the last piece...The final piece of this “OT puzzle” is something that occupational therapy practitioners are highly skilled at – activity analysis. It is essential to consider the intricate aspects of the task a person needs to perform along with all of the other pieces involved in order to determine how to help someone achieve optimal function. It’s like putting a puzzle together. OT practitioners consider the whole picture of a person’s life. We know what to tweak if something doesn’t match up quite right.

To sum it up, we aren’t going to help you get a job but now you know how we can work with you to:

  • Determine what is getting in the way of a person’s ability to live life to the fullest

and

  • Develop a plan to help overcome any limitations.

NOTE: The Occupational Therapy Practice Framework: Domain & Process, 3rd edition is a great resource that can enhance your understanding of occupational therapy. It is written in easy to understand language, appropriate for healthcare professionals and all others.

Reference:

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48. http://dx.doi.org/10.5014/ajot.2014.682006