INTERVENTIONS
Canes and Walkers
Assistive devices such as canes and walkers are being used more often as the population ages. If you’re looking for something to provide minimal help for your patient, a cane might be a better solution. Canes improve one’s ability to get up from a chair or can help with balance.
The rule of thumb for fitting a cane that I learned in my OT 881 class was t measure to the wrist crease / greater trochanter of the client, and ensure that there is a 15 degree bend in the elbow.
Walkers should be prescribed to clients to provide even more stability. In general, walkers are given to clients to keep them stable when walking. If the correct type of walker is prescribed, and if clients are taught how to use the walker correctly, walkers can decrease the risk of falls. But, if used inappropriately they can make falls more likely. Thus, knowing when to prescribe a walker and which type to prescribe is important to client safety. The three most commonly used walkers a the standard walker, the two-wheeled walker, and the four-wheeled walker.
Tips for choosing a walker:
Recommend a standard walker for clients who have an unstable gait and need to bear a significant amount of weight on the walker.
Recommend a two-wheeled (rolling) walker for clients who have an unstable gait but do not need to bear a substantial amount of weight on the walker.
Recommend a four-wheeled (Rollator) walker for clients who need a walker only for balance but not for weight bearing.
Be sure clients receive and understand instructions for how to use their walker, as improper use can lead to injury.
Wheelchair Prescription
Prescribing a wheelchair is a complex therapy intervention which aims to enhance a person’s functioning. There is no formula for prescribing a wheelchair; rather it is an incremental process. When the person and the wheelchair are well matched the impact of the person's impairment is reduced, enabling them to achieve goals, participate in life roles and improve their health and quality of life.
The therapist should adopt the following fundamental principles:
Individually assess the prospective user’s functioning and consider their personal variables such as age, goals, personality, co-morbid conditions and environment.
Involve the user and relevant others such as family in decisions throughout the prescription process.
Apply clinical reasoning at every stage of the intervention.
Use research evidence to guide reasoning and decisions.
Keep appropriate records of the intervention, including goals agreed with the user, joint assessments and outcomes.
Consult with other specialists where appropriate about specific issues, for example seating specialists or speech pathologists. This could include occupational therapists and physiotherapists consulting each other on different areas of expertise, or consulting medical specialists about future medical conditions or procedures which might affect choice of wheelchair features.
Ensure that they seek professional supervision commensurate with their skills and experience.
If seeking funding for the wheelchair, the therapist must meet the relevant qualifications and experience required by the funding body (Assistive Devices Program).
Strengthening and Endurance Training
Strengthening and endurance training are two proven interventions for increasing client performance and participation in occupations following a physical impairment. Grading of these techniques involves gradually increasing the difficulty of the tasks that a client is performing in order to increase the workload that they can withstand. Grading meets the client at their starting level of capability, and builds with them as remediation takes place.
Strengthening involves muscle hypertrophy, which is essentially building muscle. In order to build muscle, there must be sufficient stress on the muscle to elicit a change. As the muscle grows, the task is graded to be more difficult. For example, a therapist might use theraputty to increase the grip strength of a client who suffered a hand injury. As sessions go by and hand strength increases, the therapist will give tougher, firmer theraputty to the client to make the task more challenging. Designing a graded intervention for strengthening depends on many factors, making each program unique to its client.
Increasing endurance requires different techniques than strengthening, mainly it focuses on two components: high repetition number and extended time of muscle tension. The occupational therapist will try to use occupations that the client enjoys and turn them into graded tasks for increasing endurance. They might use routines that call for an increase in workload each day to increase the time spent performing occupations, and therefore grading endurance. With both endurance and strengthening, it is important that the client does not exert themselves too hard; both the client and therapist need to be vigilant in looking for signs of over-exertion.
Grading
Grading is a great intervention because it starts with the clients' capabilities and moves forward from that point. It often can incorporate meaningful occupations, increasing the likelihood the a client will adhere the intervention program and enjoy the process of rehabilitation. Grading offers direct observation of progress because clients can see how there strength and endurance increases throughout the course of rehabilitation. Here I focused on grading strengthening and endurance tasks, but grading does not have to be limited to this. It can also be used in a variety of contexts, such as return to work or exposure to phobias. For these reasons, I have decided to use grading as a tool for my future practice. It is a simple and very effective means of restoring function and ability.
Splinting
Splinting is a technique that occupational therapists can use to address issues with the hand and wrist. Splints can be effective interventions for improving hand function, avoiding deformity, correcting deformity, protecting healing structures, limiting motion and allowing tissue to remodel. In order to properly splint, the therapist must be an expert in anatomy of the hand and biomechanics. There are many things that an OT must consider when splinting such as the actions the client is likely to engage in, the type of material to use in the splint, and the likeliness that the client will adhere to wearing the splint. The splint will only be an effective intervention if the OT designs it properly and the client uses it effectively. In order to increase the likelihood of adherence, the OT should inform the client the goal and purpose in splinting, how to clean their splint, adjust their splint and how to notice edema.
Given that many OTs in a physical setting tend to focus on the upper extremity, learning how to properly employ splinting is an important intervention. Splinting requires a high level of training and practice, neither of which I have at this moment. I would like to learn these skills so that I am competent in splinting, and hope that in one of my future placements, I have the opportunity to observe and practice. Although splinting is a physical intervention and very much science based, the process of making a splint can be thought of as an art, requiring careful consideration and precision.
