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Occupational Therapy in Rheumatoid Arthritis

Comprehensive Research Notes

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1. UNDERSTANDING THE CONDITION - Relevance for OT

• Morning stiffness (>1 hour) - limits early morning ADL performance
• Symmetrical joint involvement - bilateral hand, wrist, MCP, PIP, elbow, shoulder, knee, ankle, and foot joints
• Joint deformities - ulnar deviation, swan neck deformity, boutonniere deformity, volar subluxation of MCP joints, Z-deformity of thumb
• Systemic features - fatigue, anemia, pain, depression - all impacting occupational performance
• Extra-articular manifestations - rheumatoid nodules, vasculitis, pulmonary involvement
• Disease course - flares and remissions requiring OT to adapt programs accordingly

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2. ROLE OF OCCUPATIONAL THERAPY IN RA

1. Enabling meaningful occupational performance despite disease limitations
2. Preventing secondary complications and deformity progression
3. Promoting self-management and independence
4. Addressing the biopsychosocial impact of chronic disease

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3. OBJECTIVES OF OCCUPATIONAL THERAPY IN RA

General OT Objectives

1. Maintain or increase the ability to engage in meaningful occupation - including self-care, productivity, and leisure
2. Maintain or increase joint mobility and strength - through therapeutic exercise and activity
3. Maximize physical endurance - addressing fatigue, the most disabling RA symptom
4. Minimize effects of deformity - through positioning, splinting, and joint protection
5. Increase understanding of the disease - patient education as an OT core function
6. Assist with adjustment to disability - psychosocial support, coping strategies, role adaptation
7. Promote pain management - using physical modalities, activity modification, and cognitive approaches
8. Enable return to work and social participation - vocational rehabilitation and community reintegration

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4. OT ASSESSMENT IN RA

Occupational Profile

• Roles, routines, and valued occupations
• Activity level and participation
• Work, leisure, home management, social participation

Occupational Performance Status

• Self-care (ADL/IADL): Dressing, grooming, bathing, feeding, cooking, home management
• Productivity: Work (paid/unpaid), education, caregiving
• Leisure: Rest, sleep, play, social participation

Clinical/Physical Status

• ROM: Passive and active range of all affected joints
• Strength: Hand grip, pinch strength, upper limb MMT
• Stiffness: Duration and severity of morning stiffness
• Pain: VAS or NRS, location, aggravating/relieving factors
• Swelling: Joint circumference, palpation
• Sensation: Peripheral neuropathy assessment (especially carpal tunnel syndrome - common in RA)
• Endurance: Activity tolerance, fatigue severity
• Hand function: Grip, pinch, fine motor skills, deformity classification
• Deformities: Type and severity (ulnar deviation, boutonniere, swan neck, etc.)

Psychological and Social Status

• Mood, depression, anxiety (PHQ-9, GAD-7)
• Cognitive function
• Social support network
• Disease acceptance and adjustment

Standardized Assessments Used in RA

• Health Assessment Questionnaire (HAQ) - most widely used RA disability measure
• DASH (Disabilities of Arm, Shoulder and Hand)
• COPM (Canadian Occupational Performance Measure) - client-centered goal setting
• SF-36 / PROMIS - health-related quality of life
• Grip/pinch dynamometry
• Jamar dynamometer
• DAS-28 (Disease Activity Score - used by rheumatologist, informs OT)

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5. OT INTERVENTION AREAS IN RA

5.1 Joint Protection

1. Respect pain - stop or modify activities if pain persists >1 hour after activity
2. Maintain muscle strength and joint ROM - through regular exercise
3. Use each joint in its most stable anatomical and functional plane - avoid positions of deformity
4. Avoid positions that cause deformity - avoid tight pinch, strong ulnar deviation forces, prolonged grip
5. Use the strongest/largest joint available - use shoulders/elbows instead of wrists/fingers; use palm instead of fingers
6. Avoid staying in one position - change positions frequently
7. Avoid fatigue - balance rest and activity
8. Use assistive devices - reduce forces on joints

• Wrists/hands: Avoid wringing, tight grip, forceful pinch; use adapted tools (built-up handles, lever taps)
• Shoulders/elbows: Use for carrying loads rather than hands; use two-handed technique
• Knees/hips: Avoid prolonged kneeling, sitting in low chairs; use raised toilet seat

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5.2 Energy Conservation and Fatigue Management

1. Planning - plan activities in advance; alternate heavy and light tasks; schedule rest periods
2. Prioritizing - identify essential vs. non-essential tasks; delegate when possible
3. Pacing - work for short periods with regular rest breaks; avoid the "boom and bust" cycle
4. Positioning - work at the correct height; use seated positions where possible; avoid awkward postures

• Activity diaries to identify fatigue patterns
• Sleep hygiene education
• Gradual graded activity programs
• Identifying and modifying fatigue triggers
• Group fatigue management programs (evidence-based)

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5.3 Therapeutic Exercise

• Maintain and increase joint range of motion (ROM)
• Build muscle strength to stabilize joints and reduce pain
• Improve endurance and cardiovascular fitness
• Maintain hand function

• ROM/stretching exercises - gentle active and active-assisted movements
• Strengthening exercises - isometric (during flares), then isotonic and resistive as tolerated
• Aerobic/cardiovascular conditioning - cycling, hydrotherapy, walking (well-evidenced in RA)
• Hydrotherapy - warm water reduces pain and stiffness, facilitates movement
• Tai chi and yoga - improve balance, flexibility, reduce stress (emerging evidence)
• Neuromuscular and balance training

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5.4 Splinting / Orthoses

• Worn at night to rest inflamed joints in functional position
• Reduces pain and inflammation during acute flares
• Wrist in 20-30° extension, MCPs in slight flexion, IPs in extension

• Worn during activity to support and stabilize joints
• Wrist working splints - stabilize wrist during ADL
• MCP ulnar deviation splints - counteract ulnar drift forces during activity
• Ring splints (silver ring splints / Oval-8) - for swan neck and boutonniere deformities
• Thumb spica splints - support CMC/IP joint in de Quervain's or thumb instability

• MCP extension assist splint post-MCP arthroplasty
• Worn during the day to guide movement and prevent recurrence of deformity

• Must not apply pressure over bony prominences
• Should be lightweight (thermoplastic materials preferred)
• Must not exacerbate deformity or restrict needed motion
• Regular review and adjustment required as disease changes

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5.5 Activities of Daily Living (ADL) Training and Adaptive Equipment

• Modified methods of task performance (e.g., seated dressing, use of dressing aids)
• Simplified task sequences
• Use of the strongest joints for load-bearing
• Two-handed techniques

• Environmental assessment to identify hazards and barriers
• Recommendation for home modifications (grab rails, ramp, raised surfaces)
• Referral to housing services as required

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5.6 Physical Agent Modalities (PAM)

• Heat therapy: Paraffin wax bath (for hands), moist heat packs, warm soaks - reduce stiffness, improve circulation
• Cold therapy: Ice packs - reduce swelling and pain in acute flares
• Hydrotherapy: Warm water exercise - combines heat benefits with exercise
• Transcutaneous Electrical Nerve Stimulation (TENS): Pain relief
• Ultrasound: Used in hand therapy for tendon involvement

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5.7 Self-Management Education

• Disease education: Understanding RA, disease course, medications, and monitoring
• Medication adherence: Importance of DMARDs, recognition of side effects
• Flare management: What to do during a flare (local rest, cold packs, contact rheumatology team)
• Lifestyle modification: Diet, smoking cessation, weight management, exercise
• Psychological coping strategies: Stress management, problem-solving, acceptance
• Group-based self-management programs (e.g., Arthritis Self-Management Program - ASMP by Lorig et al.) - evidence-based, OT-led programs

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5.8 Psychological Support and Adjustment

• Depression (2-3x more common in RA than general population)
• Anxiety, fear of disability progression, loss of identity and roles
• Body image changes from deformity

• Cognitive behavioral approaches - within OT scope; mood and pain management
• Motivational interviewing - facilitating behavior change
• Role adaptation - modifying roles rather than abandoning them
• Meaning and purpose - reengaging with valued occupations
• Group therapy - peer support, social connection

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5.9 Work Rehabilitation / Vocational Rehabilitation

• Workplace assessment - on-site ergonomic evaluation
• Work modification - task adaptation, pacing at work, flexible hours
• Employer liaison - advising on reasonable adjustments
• Assistive technology for work - ergonomic equipment, voice recognition software
• Functional Capacity Evaluation (FCE) - objective work capacity assessment
• Work hardening programs - graded return-to-work programs
• Return-to-work planning - goal setting, graded re-entry

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5.10 Sexual Advice and Intimacy

• Joint protection during intimacy
• Positioning advice
• Fatigue management in relation to sexual activity
• Psychological aspects of body image and relationships

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6. TREATMENT PRECAUTIONS IN RA

1. Respect pain - pain that persists >1 hour post-activity indicates over-exertion
2. Avoid fatigue - plan adequate rest within all programs
3. Avoid stresses on inflamed/unstable joints - no resistive exercise to acutely inflamed joints
4. Be aware of sensory impairments - carpal tunnel, peripheral neuropathy (affects sensation, grip)
5. Cautious with pharmacological side effects - corticosteroid osteoporosis (fracture risk), immunosuppression (wound healing), NSAIDs (GI effects affecting participation)
6. Cervical spine precautions - atlanto-axial instability in long-standing RA - avoid neck extension/flexion exercises without imaging clearance
7. Post-surgical precautions - strict protocols following MCP arthroplasty, tendon repair, wrist fusion

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7. FRAMES OF REFERENCE AND THEORETICAL MODELS

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8. DISEASE STAGE AND OT APPROACH

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9. OUTCOMES AND EVIDENCE BASE

• Joint protection programs have strong RCT evidence for reducing pain, improving function, and slowing radiological progression (Hammond et al., multiple RCTs)
• Fatigue management programs - evidence for reduced fatigue and improved function (Hewlett et al.)
• Aerobic exercise in RA - improves cardiovascular fitness, reduces fatigue, no evidence of joint damage (Stenström, 1994; Arthritis Rheum)
• Occupational therapy overall - Siegel et al. (2017) systematic review in AJOT confirms effectiveness of OT for adults with RA in multiple domains (ADL, joint protection, fatigue, QoL)
• Work rehabilitation - evidence supports early OT work interventions to prevent work disability

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10. SUMMARY TABLE: OT ROLE IN RA

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11. REFERENCE BOOKS (As Specified)

1. Pedretti's Occupational Therapy: Practice Skills for Physical Dysfunction (Pendleton & Schultz-Krohn) - Chapters on musculoskeletal conditions, splinting, ADL, upper extremity management
2. Occupational Therapy for Physical Dysfunction (Radomski & Trombly) - Chapter 39: Rheumatoid Arthritis, Osteoarthritis, and Fibromyalgia - primary reference; contains detailed assessments, case examples (Ms. B - return to work; Mrs. B - homemaking; Mrs. D - post-MCP arthroplasty), comprehensive intervention list
3. Occupational Therapy and Physical Dysfunction (Turner, Foster & Johnson) - principles and joint protection
4. Willard & Spackman's Occupational Therapy - framework, roles, biopsychosocial approach
5. Introduction to Occupational Therapy (Hussey, Sabonis-Chafee, O'Brien) - foundational role of OT in chronic disease

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Sources used: Rheumatology 2-Volume Set (Elsevier 2022); Goldman-Cecil Medicine; Radomski - OT for Physical Dysfunction (TNAIOTA PDF extract); Arthritis Movement OT & Arthritis resource; NCAHP OT Draft Curriculum; Siegel et al. AJOT 2017 systematic review reference.

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Occupational Therapy in Leprosy (Hansen's Disease)

Comprehensive Research Notes

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1. UNDERSTANDING LEPROSY - Foundation for OT Practice

Classification (Ridley-Jopling Spectrum)

WHO Classification (for treatment and OT)

• Paucibacillary (PB): 1-5 skin lesions (TB spectrum)
• Multibacillary (MB): >5 skin lesions (LL spectrum) - highest risk of nerve damage and disability

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2. NERVE DAMAGE AND DISABILITY IN LEPROSY - Central to OT

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3. WHO DISABILITY GRADING SYSTEM - OT Assessment Framework

For Hands and Feet:

For Eyes:

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4. DEFORMITIES IN LEPROSY - OT Clinical Reference

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5. MULTIDISCIPLINARY TEAM IN LEPROSY

• Leprosy control officer / Dermatologist (primary treatment)
• Neurologist/neurophysiologist (nerve function diagnosis)
• Rehabilitation physician
• Occupational therapist (orthotics, ADL, functional rehabilitation)
• Physiotherapist
• Reconstructive surgeon (tendon transfers, corrective surgery)
• Ophthalmologist
• Psychologist
• Social worker
• Community-based rehabilitation (CBR) workers

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6. OBJECTIVES OF OCCUPATIONAL THERAPY IN LEPROSY

Primary OT Objectives

1. Prevention of disability - the single most important objective; early intervention prevents Grade 1 progressing to Grade 2 disability
2. Prevention of deformity progression - through splinting, positioning, and ROM exercises
3. Restoration and maximization of function - improving muscle power, joint range, and functional performance
4. Training in self-care - teaching protective behaviours for insensitive hands, feet, and eyes
5. ADL training - enabling independence in daily activities despite physical limitations
6. Splinting and assistive device provision - custom orthoses, protective footwear, self-help devices
7. Vocational rehabilitation - training, retraining, and resettlement in suitable employment
8. Psychosocial rehabilitation - addressing stigma, social isolation, amotivational syndrome
9. Community reintegration - facilitating participation in family, social, and work life
10. Functional assessment - objective, repeated evaluation of functional capabilities to monitor progress or deterioration

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7. OT ASSESSMENT IN LEPROSY

Comprehensive Functional Assessment (OT)

A. Physical Assessment

• Sensory testing: Monofilament testing (Semmes-Weinstein), ball-point pen test, loss of sensation mapping on hands, feet, and face
• Motor/muscle assessment: Manual Muscle Testing (MMT) of all affected peripheral nerve distributions; grip and pinch strength (dynamometry)
• Range of Motion (ROM): Active and passive ROM of fingers, wrist, thumb, ankle, toe joints
• Deformity assessment: Type, severity, and functional impact of deformities
• Wound/ulcer assessment: Location, depth, stage of plantar ulcers, trophic changes
• Eye assessment: Lagophthalmos, corneal sensation, visual acuity
• Nerve function assessment: Voluntary Muscle Testing (VMT) and Sensory Testing (ST) - assessed monthly during treatment

B. Functional/Occupational Assessment

• Hand function: Object manipulation, grip patterns, fine motor tasks
• Activities of Daily Living (ADL): Bathing, dressing, grooming, feeding, toileting
• IADL: Cooking, housework, childcare, shopping, financial management
• Work/vocational capacity: Current job demands, physical requirements, adaptability
• Leisure and social participation

C. Psychosocial Assessment

• Psychological status: Depression, anxiety, stigma perception, self-esteem
• Social functioning: Family support, community acceptance, social isolation
• Economic status: Livelihood, employment, financial dependence
• Educational background: Literacy (impacts self-care education methods)

D. Environmental Assessment

• Home environment: Accessibility, hazards for insensate limbs (hot surfaces, sharp objects)
• Work environment: Demands, modifications required
• Community barriers and facilitators

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8. OT INTERVENTION IN LEPROSY

8.1 Self-Care Education (Highest Priority Intervention)

"In leprosy (more than in most other disabilities), due to sensory loss, the patient must be taught and retaught the care of hands, feet and eyes until it becomes second nature to him." (Mehta, Occupational Therapy in Leprosy, ILA Journal)

Care of Insensitive Hands:

• Daily inspection of hands using a mirror and magnifying glass
• Soaking hands in warm water (test temperature first with intact skin) and applying oil/cream to prevent cracking
• Using protective gloves for work involving heat, sharp objects, rough surfaces
• Avoiding tight grip on tools - use built-up handles
• Learning to look instead of feel (visual compensation for sensory loss)
• Avoiding prolonged use of insensitive hands without inspection

Care of Insensitive Feet:

• Daily inspection of soles using a mirror
• Soaking feet and applying moisturising oil/cream to prevent cracking and callosities
• Protective footwear - microcellular rubber (MCR) footwear, moulded footwear for deformed feet
• Avoiding walking barefoot
• Appropriate management of callosities (trimming, padding)
• Wound care for plantar ulcers - offloading, dressings

Care of Insensitive Eyes (Lagophthalmos):

• Regular blinking exercises to prevent corneal drying
• Using sunglasses and hats outdoors (reduce UV exposure)
• Applying artificial tears / eye drops regularly
• Taping eyelids closed at night if lagophthalmos is present
• Regular visual inspection using a mirror

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8.2 Splinting / Orthotics

A. Preventive Splints (to prevent deformity)

• Applied early, before fixed deformity develops
• Lively/Dynamic splints to maintain passive ROM while nerve recovers
• Anti-claw splints - maintain MCP joints in flexion during acute nerve damage phase

B. Corrective Splints (to correct mobile deformity)

• Used when deformity is mobile (not fixed)
• Knuckle-bender splints for claw hand correction
• Dynamic extension splints for wrist drop
• Used in conjunction with exercises

C. Functional/Working Splints

• Support weakened or paralyzed joints during activity
• Wrist support splints for wrist drop
• Thumb opposition splints for median nerve palsy
• Foot-drop splints / ankle-foot orthoses (AFO) for foot drop

D. Post-surgical Splints

• Following tendon transfer surgery, the OT makes and monitors dynamic splints per surgical protocol
• Dynamic MCP extension assist splints following intrinsic reconstruction

E. Protective Footwear and Insoles

• MCR (Micro-Cellular Rubber) chappals/sandals - redistributes pressure, protects insensate sole
• Moulded footwear for severe foot deformities
• Rocker-bottom soles for forefoot ulcers

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8.3 Exercise Programme

• ROM exercises - active and passive, to maintain joint mobility in paralyzed segments
• Strengthening exercises - for muscles not affected by nerve damage (compensatory strengthening)
• Functional activities as exercise - using purposeful activity to restore muscle function
• Tendon-gliding exercises - to prevent adhesions in the hand
• Post-surgical exercises - following tendon transfers (e.g., Zancolli lasso for claw hand)

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8.4 Activities of Daily Living (ADL) Training

Adaptive Techniques:

• Visual compensation - looking at what the hand is doing instead of relying on sensation
• Pressure distribution techniques - spreading load across multiple fingers/palm
• Temperature management - testing water/hot surfaces with intact skin areas
• Grip pattern modification - using adapted tools to reduce pressure on insensate areas
• One-handed techniques where applicable (post-amputation or severe deformity)

Adaptive Equipment / Assistive Devices:

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8.5 Vocational Rehabilitation

1. Vocational assessment - identifying work capacities, aptitudes, and transferable skills
2. Work simulation - using workshop activities to assess and improve work-related skills
3. Pre-vocational training - graded work activities building toward employment
4. Vocational training - learning new trades suitable for physical capacity (e.g., tailoring, weaving, bookbinding, leather work)
5. Workplace modification - ergonomic adaptations (tool handles, seating, workstation height)
6. Employer liaison - educating employers, negotiating adjustments
7. Monitoring and follow-up - checking that patients remain employed and have not had setbacks

"The OT sections should be kept like normal workshops, with stress on self-protection for sensory loss." (Mehta, ILA Journal)

• Goal setting that is realistic and patient-centred
• Gradual reintroduction to activity
• Social group activities to rebuild confidence
• Peer support from successfully rehabilitated leprosy patients

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8.6 Psychosocial Rehabilitation

• Counselling - disease education, correcting misconceptions (leprosy is curable, not highly contagious during MDT)
• Stigma reduction - community education, empowerment of patients
• Self-stigmatisation - Harrison's (22E) specifically notes that possible self-stigmatisation must be discussed with patients
• Body image - adjustment to physical changes (absorption of digits, facial changes)
• Depression and anxiety - screening and referral; supporting adjustment
• Role re-engagement - maintaining or resuming roles as parent, worker, community member
• Group therapy - peer support groups; using successfully rehabilitated patients as role models
• Family education - educating family members to support the patient and avoid isolation

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8.7 Community-Based Rehabilitation (CBR)

• Training community health workers (CHWs) and family members in self-care monitoring
• Home visits for assessment and follow-up
• Linking patients to government welfare benefits (as legally entitled)
• Facilitating access to community resources
• Advocating for social inclusion and anti-discrimination
• Liaising with leprosy colonies and support organisations

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9. DISEASE STAGES AND OT APPROACH

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10. OT IN LEPROSY REACTIONS

• Immediate resting splints to rest inflamed nerves
• Close nerve function monitoring (VMT + ST) - report any deterioration urgently
• Modify or suspend therapeutic exercises to inflamed nerve territories
• Oedema management - positioning, elevation
• Continue self-care education - patient may be more susceptible to injury during reaction
• Psychological support - reactions are alarming to patients; reassurance is critical

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11. WOUND CARE / PLANTAR ULCER MANAGEMENT (OT Component)

• Pressure off-loading - total contact casting, MCR footwear, crutch training
• Wound care education - teaching patients to clean, dress, and inspect wounds
• Prevention of recurrence - footwear prescription, activity modification
• Callosity management - pumice/trimming education, moisturising protocols
• Return to ambulation - graduated weight-bearing after ulcer healing with protective footwear

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12. OT IN LEPROSY - SUMMARY TABLE

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13. FRAMES OF REFERENCE APPLICABLE IN LEPROSY OT

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14. TREATMENT PRECAUTIONS

1. Never apply heat to insensate skin - severe burns can occur without patient awareness
2. Avoid pressure on insensate areas - pressure sores and ulcers develop silently
3. Monitor nerve function regularly - silent nerve damage during reactions requires urgent response
4. Cervical spine awareness - patients on long-term steroids (for reactions) have osteoporosis risk
5. Immunosuppression - patients on clofazimine/steroids - wound healing may be impaired
6. Psychological fragility - stigma and isolation make patients vulnerable; approach with sensitivity and non-judgment
7. Post-surgical protocols - strict adherence to tendon transfer splinting protocols

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15. RELEVANT REFERENCE BOOKS FROM YOUR LIST

Books 9 and 10 (pediatric OT texts by Case-Smith and Kramer/Hinojosa) are not directly relevant to leprosy in adults, though principles of sensory processing may apply in cases of pediatric leprosy.

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Sources: Harrison's Principles of Internal Medicine 22E (2025); Park's Textbook of Preventive and Social Medicine; Mehta - "Occupational Therapy in Leprosy", International Journal of Leprosy Vol 44(3); Leprosyhealth.org - OT in Leprosy; ERIC - Role of the Vocational Counselor/Physical Therapist in Leprosy; Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Goldman-Cecil Medicine.

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Occupational Therapy in Cardiac Dysfunctions

Comprehensive Research Notes

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1. UNDERSTANDING CARDIAC DYSFUNCTIONS - Foundation for OT Practice

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2. CLASSIFICATION SYSTEMS - Clinical Tools for OT Activity Planning

NYHA Functional Classification of Heart Failure

ACC/AHA Heart Failure Staging (A-D)

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3. METABOLIC EQUIVALENTS (METs) - Core OT Tool for Cardiac Activity Grading

"The maximum amount of metabolic work that an individual can perform corresponds to overall cardiovascular fitness. Each additional MET correlated with a 13% decrease in likelihood of all-cause mortality." (Sabiston Textbook of Surgery, /textbooks/9780443124341/)

MET Level Activity Reference (OT Clinical Guide)

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4. PHASES OF CARDIAC REHABILITATION AND OT ROLE

"Phase 1, the inpatient phase, was provided by a collaborative team of cardiologists, physical and occupational therapists, social workers, and even vocational counselors." (Fuster and Hurst's The Heart, 15th Ed, /textbooks/9781264257560/)

Phase 1 - Acute Inpatient (5-14 days; METs 1-2, discharge at 3.5)

1. Establish baseline functional status (ADL, FIM, activity tolerance)
2. Teach patient/family energy conservation techniques
3. Grade progressive ADL retraining (lying → sitting → standing → ambulating)
4. Educate on cardiac precautions, warning signs, when to stop activity
5. Introduce METs concept and apply to daily tasks
6. Assess and address psychological response to cardiac event
7. Bridge the patient toward Phase 2 outpatient rehabilitation
8. Provide disease management education (risk factors, medications, lifestyle)

• Bed mobility and grooming in lying/sitting (1-2 METs)
• Sitting balance activities, seated self-care
• Standing tolerance for grooming at sink (2-3 METs)
• Slow ambulation within ward (2-3 METs)
• Introduction of adaptive equipment (tub seat, long-handled shoe horn)
• Teach family caregiver role

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Phase 2 - Subacute Outpatient Rehabilitation (up to 12 weeks; METs 3.5 → 5-6)

1. Progress ADL/IADL independence with reduced energy expenditure
2. Advance activity tolerance from 3.5 to 5-6 METs
3. Deep dive energy conservation and pacing training
4. Home assessment and environmental modification
5. Work rehabilitation planning
6. Sexual activity counseling
7. Stress management and psychosocial support
8. Caregiver education and training
9. Risk factor modification education (smoking, diet, weight, blood pressure)

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Phase 3 - Long-term Outpatient / Community (12+ weeks; METs 5-6 → 6+)

1. Work hardening and return-to-work programming
2. Facilitate return to leisure activities (including vigorous activity)
3. Maintenance exercise program
4. Long-term self-management and monitoring
5. Community reintegration

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Phase 4 - Maintenance / Community (Ongoing; METs 6+)

1. Maintain gains from Phases 1-3
2. Ongoing education and risk factor management
3. Independent participation in meaningful occupations

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5. OT ASSESSMENT IN CARDIAC DYSFUNCTION

Initial OT Evaluation Components:

A. Occupational Profile

• Prior level of function (PLOF) - home, work, leisure
• Roles, routines, and valued occupations
• Personal goals for therapy
• Living situation and social support

B. Standardized Assessment Tools

• Functional Independence Measure (FIM) - used in inpatient setting for ADL baseline
• Canadian Occupational Performance Measure (COPM) - client-centred goal identification
• 6-Minute Walk Test (6MWT) - functional endurance proxy
• Borg Rating of Perceived Exertion (RPE) Scale - subjective exertion monitoring (6-20 scale; target 11-13 "moderate" in early phases)
• Duke Activity Status Index (DASI) - estimates METs from self-reported activity
• PHQ-9 / GAD-7 - depression and anxiety screening (high prevalence post-MI)
• Barthel Index - ADL independence

C. Physical Status Monitoring

• Vital signs before, during, after activity: Heart rate (HR), blood pressure (BP), respiratory rate (RR), oxygen saturation (SpO2)
• Cardiac monitoring: Telemetry review; ECG rhythm during Phase 1 sessions
• Symptoms: Angina, dyspnoea, dizziness, palpitations, diaphoresis
• Activity tolerance: Distance walked, time standing, fatigue onset

D. Activity Analysis

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6. OBJECTIVES OF OCCUPATIONAL THERAPY IN CARDIAC DYSFUNCTION

General OT Objectives:

1. Restore and maximise independence in ADL and IADL safely within cardiac parameters
2. Prevent deconditioning and secondary complications through graded activity
3. Educate on energy conservation to reduce cardiac workload during daily tasks
4. Grade progressive activity using MET levels aligned to rehabilitation phase
5. Reduce fear of activity (kinesiophobia) and foster confidence in physical ability
6. Manage psychosocial impact of cardiac disease (depression, anxiety, role loss)
7. Facilitate return to work and meaningful occupations
8. Educate on risk factor modification and lifestyle change
9. Address sternal/surgical precautions (post-CABG/valve surgery)
10. Equip with self-management skills to recognise warning signs and respond appropriately

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7. KEY OT INTERVENTIONS

7.1 Energy Conservation - The "4 P's"

• Keep items within reach - avoid unnecessary trips
• Use a cart/trolley to move items
• Use lightweight tools and equipment
• Avoid isometric exercises (Valsalva manoeuvre raises BP acutely)
• Avoid extremes of temperature (hot showers, cold outdoor work)
• Avoid heavy meals before activity

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7.2 ADL and IADL Retraining

Bathing/Showering:

• Seated shower using a tub bench or shower chair (reduces MET demand from 3-4 to 2-3)
• Tepid (not hot) water - hot water causes vasodilation, increases cardiac demand
• Handheld showerhead
• Non-slip mat, grab rails

Dressing:

• Seated dressing
• Loose, front-fastening clothing
• Long-handled shoe horn and sock aid (avoids bending which increases intrathoracic pressure)
• Elastic laces

Grooming:

• Seated at sink or vanity
• Support elbows on surface (reduces overhead arm work)

Meal Preparation (IADL):

• Seated at counter height
• Small, frequent preparations vs. one long session
• Pre-cut, pre-washed foods; microwave vs. stove
• Rest before and after cooking

Household Management (IADL):

• Delegate heavy tasks (vacuuming, scrubbing, carrying laundry)
• Break tasks into short segments with rest breaks
• Use wheeled trolley for carrying

Sexual Activity:

• Addressed explicitly in cardiac rehabilitation
• Generally safe to resume when patient can climb 2 flights of stairs without symptoms (~4-5 METs)
• Educate on positioning (less demanding positions), timing (avoid after heavy meals/alcohol), warning signs

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7.3 Adaptive Equipment and Assistive Devices

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7.4 Sternal Precautions (Post-CABG and Valve Surgery)

• No pushing, pulling, or lifting > 5-10 lbs (2.5-5 kg)
• No reaching behind back
• No reaching overhead bilaterally
• Log-roll technique for getting in/out of bed (avoid using arms to push up)
• Support sternum with pillow when coughing/sneezing ("heart pillow" technique)
• No driving (inability to react quickly; airbag risk)

• Teach log-roll bed mobility
• Train all ADLs within precaution parameters
• Prescribe adaptive equipment to substitute restricted movements (long-handled shoe horn, sock aid, reacher)
• Educate patient and caregiver on all precautions
• Monitor incision during activity - report any sternal instability signs

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7.5 Pacemaker Precautions

• Avoid raising affected arm (usually left) above shoulder for 4-6 weeks post-implant
• Avoid strong magnetic fields
• Educate on device identification card
• Activity restrictions specific to device programming (set rate limits)
• OT trains ADLs within these restrictions using adaptive techniques

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7.6 Self-Monitoring and Symptom Recognition

• Chest pain, pressure, or tightness (angina)
• Dyspnoea at rest or disproportionate to activity
• Dizziness, lightheadedness, or near-syncope
• Palpitations or irregular heartbeat
• Unusual sweating (diaphoresis)
• Nausea

• Target HR during activity usually set by cardiology (e.g., "not to exceed 120 bpm" or "RPE 11-13")
• OT teaches patients to monitor pulse before, during, and after activity
• Teach Borg RPE scale (12-13 = "somewhat hard" is typically the Phase 2 target)

• OT educates on safe BP ranges during activity
• Stop activity if systolic BP falls >10 mmHg from baseline during exercise (sign of cardiac compromise)

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7.7 Psychosocial Intervention

• Depression affects 20-30% of post-MI patients and doubles mortality risk
• Anxiety (fear of re-infarction, fear of activity = cardiac phobia)
• Role loss - loss of identity as worker, breadwinner, athlete
• Relationship strain - partner anxiety, sexual dysfunction
• Grief - loss of prior physical capacity and lifestyle

• Activity-based graded exposure - gradually reintroducing feared activities to reduce cardiac phobia
• Cognitive-behavioral approaches - challenging catastrophic thinking about activity
• Motivational interviewing - facilitating lifestyle changes (smoking, diet, exercise)
• Role adaptation - modifying rather than abandoning meaningful roles
• Stress management - relaxation techniques, mindfulness, breathing exercises
• Group-based cardiac rehabilitation - peer support, normalization of experience
• Caregiver/family support - educating family to support without over-protecting

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7.8 Risk Factor Modification Education

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7.9 Work and Vocational Rehabilitation

• Work capacity evaluation using MET equivalents of job demands
• Graduated return-to-work plan aligned to rehabilitation phase
• Work hardening - progressive simulation of job tasks
• Workplace modification - ergonomic adaptations, pacing at work
• Employer liaison - advising on reasonable adjustments
• Driving assessment - typically cleared when patient reaches 4-5 METs capacity and physician approval obtained

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7.10 Home Assessment and Environmental Modification

• Home visit to identify barriers and hazards
• Bedroom on ground floor if stairs are a barrier in early recovery
• Remove trip hazards (rugs, clutter)
• Install grab rails, raised toilet seat, shower chair
• Rearrange kitchen to reduce reaching and carrying
• Move frequently used items to accessible heights and locations

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8. CARDIAC DYSFUNCTION-SPECIFIC OT CONSIDERATIONS

Congestive Heart Failure (CHF) - Special OT Focus:

• Fluid management monitoring - daily weights, recognising signs of decompensation
• Dyspnoea management - body positioning (head of bed elevation 30-45°), fan therapy
• Activity pacing with symptom-based guidance - stop when breathlessness exceeds mild
• Medication adherence - educating on diuretics, timing of activity vs. diuretic effect (avoid activity within 2 hrs of diuretic dose due to urge to void)
• Palliative care OT - for NYHA Class IV/Stage D: comfort, dignity, meaningful engagement within profound limitations, caregiver support

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9. CONTRAINDICATIONS TO OT ACTIVITY IN CARDIAC PATIENTS

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10. OT PRECAUTIONS DURING CARDIAC ACTIVITY

1. Monitor vitals continuously during all activity sessions
2. Avoid Valsalva manoeuvre - no isometric exercise, breath-holding, or straining
3. Avoid temperature extremes - no hot baths, cold outdoor work in early phase
4. Rest 1-2 hours after meals before activity
5. Avoid emotional stress during activity sessions
6. Morning stiffness awareness - cardiac events more common in morning; gentle warm-up critical
7. Medication timing - be aware of beta-blockers (blunts HR response, use RPE instead of HR targets)
8. Sternal precautions as described (post-surgical patients)
9. SpO2 monitoring - maintain >92% during activity; reduce intensity if dropping
10. Stop activity immediately if warning signs develop

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11. OUTCOMES AND EVIDENCE BASE

• Cardiac rehabilitation reduces all-cause mortality significantly
• Meta-analysis of 34 trials: exercise-based CR associated with significant reduction in cardiac mortality
• Safety is well-established: 1 cardiac arrest per 116,906 patient-hours; 1 MI per 219,970 patient-hours
• CR improves exercise capacity, daily activity performance, psychological well-being, and quality of life
• CR reduces re-hospitalisation rates and downstream medical costs
• OT-specific evidence: Systematic reviews confirm OT improves ADL independence, energy conservation uptake, and self-management in cardiac populations

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12. PHASES AND OT ROLE - SUMMARY TABLE

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13. FRAMES OF REFERENCE IN CARDIAC OT

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14. RELEVANT REFERENCE BOOKS FROM YOUR LIST

Books 9 and 10 (pediatric OT) are not directly applicable to adult cardiac dysfunction. However, principles of graded activity and functional goal-setting are universal across practice areas.

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Sources used: Fuster and Hurst's The Heart, 15th Edition (/textbooks/9781264257560/); Braunwald's Heart Disease 2 Vol Set (/textbooks/9780323722193/); Sabiston Textbook of Surgery (/textbooks/9780443124341/); Goodman & Gilman's Pharmacological Basis of Therapeutics; PDH Therapy - The Role of OT in Cardiac Rehabilitation; myotspot.com - MET Levels in Cardiac Rehab; OccupationalTherapy.com - Living with Heart Failure OT; BOT Portal - OT Goals for Cardiac Conditions.

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Occupational Therapy in Complications of Diabetes Mellitus

Comprehensive Research Notes

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1. OVERVIEW: DIABETES MELLITUS AND ITS COMPLICATIONS

Classification of Complications

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2. COMPLICATIONS IN DETAIL - Clinical Foundation for OT Practice

2.1 Diabetic Peripheral Neuropathy (DPN) - Most Common Complication

A. Distal Symmetric Polyneuropathy (DSPN) - Most Common Form

• Symmetric sensory loss and pain beginning in feet, spreading proximally ("stocking-and-glove distribution")
• Symptoms: numbness, tingling, burning, hyperesthesia, dysesthesia, pain at rest (worsens at night)
• Physical signs: sensory loss to 10-g monofilament and vibration, loss of ankle reflexes, abnormal position sense, muscular atrophy, foot drop
• Loss of Protective Sensation (LOPS) - the single most dangerous consequence for OT:
  • Patient unaware of injury from heat, pressure, friction
  • Major risk factor for foot ulceration, falls, and lower limb amputation

B. Autonomic Neuropathy

• Cardiovascular: Decreased heart rate variability, resting tachycardia, orthostatic hypotension (major falls risk; directly impacts safe transfer and mobility in OT)
• Hypoglycaemia unawareness - reduced epinephrine response; risk of sudden collapse during activity
• Gastroparesis - delayed gastric emptying; impacts meal preparation, feeding, medication timing
• Bladder dysfunction - urinary retention; impacts toileting independence and IADL
• Sudomotor dysfunction - anhidrosis of feet → dry, cracking skin → portal for infection

C. Upper Limb Manifestations (Critical for OT Hand Therapy)

• Cheiroarthropathy (Diabetic Hand Syndrome/Prayer Sign): Limited joint mobility, thickened skin; reduced ROM in fingers; affects grip, pinch, and fine motor tasks
• Dupuytren's Contracture: Palmar fascia fibrosis; flexion contracture of fingers
• Trigger Finger (Stenosing Tenosynovitis): Locking of finger in flexion; impacts grip and release
• Carpal Tunnel Syndrome (CTS): Median nerve compression; pain, weakness of thenar eminence, sensory loss in radial 3.5 fingers
• Adhesive Capsulitis (Frozen Shoulder): Severe shoulder ROM restriction; impacts reaching, overhead activity, dressing

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2.2 Diabetic Retinopathy - Leading Cause of Blindness

• Background retinopathy: Microaneurysms, hemorrhages, exudates, macular edema - most common cause of decreased vision
• Proliferative retinopathy: New vessel formation → vitreous hemorrhage → tractional retinal detachment → severe vision loss
• Macular edema: Impairs central vision used for reading, writing, fine tasks

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2.3 Diabetic Nephropathy

• Progressive kidney disease → reduced renal clearance → fatigue, anaemia, fluid retention
• End-stage renal disease (ESRD) → dialysis dependency → severely impacts daily schedule, energy, independence

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2.4 Cardiovascular Complications (Macrovascular)

• Coronary artery disease (CAD) and myocardial infarction - cardiac rehabilitation (see cardiac dysfunction notes)
• Stroke - neurological rehabilitation
• Peripheral Artery Disease (PAD) - claudication, ischemic pain, poor wound healing

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2.5 Diabetic Foot Ulcers and Lower Limb Amputation

• Foot ulcers: 44% five-year mortality after onset of a new diabetic foot ulcer; mean survival of 50 months
• Amputation: Most lower extremity amputations are performed for complications of diabetes or arterial insufficiency
• Patient education reduces amputation risk by 50-85% - this is a core OT function

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2.6 Psychological Complications

• Depression: 2-3x more prevalent in people with diabetes vs. general population
• Diabetes distress: Emotional burden of self-management demands; distinct from clinical depression
• Anxiety: Fear of hypoglycaemia, injections (needle phobia), complications
• Burnout: Exhaustion from relentless self-management demands
• Self-stigma: Shame and blame (particularly Type 2 DM perceived as "self-caused")

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3. OT ASSESSMENT IN DIABETES COMPLICATIONS

3.1 Occupational Profile

• Roles, routines, and valued occupations
• Current self-management routines (insulin administration, blood glucose monitoring, foot care)
• Work demands and leisure activities
• Social support network and shared responsibilities in diabetes management
• Barriers to self-management (knowledge, skill, motivation, access, environment)

3.2 Standardised Assessment Tools

3.3 Physical/Clinical Assessment

• Sensory assessment: Monofilament (LOPS screening), vibration, temperature sensation in feet and hands
• Motor assessment: MMT, hand grip and pinch strength
• ROM: All upper limb joints (fingers, wrist, shoulder - cheiroarthropathy, frozen shoulder)
• Skin integrity: Inspection of feet for callouses, cracks, blisters, ulcers, nail problems
• Oedema: Ankle/foot oedema (cardiac, renal, venous)
• Vision: Functional vision - ability to read glucometer, see syringe markings, inspect feet

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4. OBJECTIVES OF OCCUPATIONAL THERAPY IN DIABETES COMPLICATIONS

Primary OT Objectives:

1. Enable and optimise self-management of diabetes - the central OT role unique to this condition
2. Prevent complications and secondary disability - particularly amputation through foot care education
3. Restore and maintain ADL/IADL independence despite physical complications
4. Adapt self-management tasks to accommodate visual impairment, motor impairment, sensory loss
5. Educate on protective behaviours for insensate limbs (same principles as leprosy)
6. Manage upper extremity complications through hand therapy
7. Address falls risk from neuropathy and orthostatic hypotension
8. Facilitate post-amputation rehabilitation (where diabetic complications have led to amputation)
9. Promote psychosocial well-being - depression, distress, burnout, adjustment
10. Facilitate lifestyle modification for glycaemic control and risk reduction
11. Support return to work and community participation
12. Educate caregivers and family in supporting self-management

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5. OT INTERVENTIONS BY COMPLICATION

5.1 OT for Peripheral Neuropathy (Sensory Loss)

Protective Sensory Education for the Feet (Highest Priority):

• Wear shoes at all times - never walk barefoot
• Inspect feet daily using a mirror for sole and between toes; report erythema, ulceration, nail problems
• Bathe feet daily with mild soap and soft brush; pay attention to web spaces (trap moisture)
• Dry thoroughly between toes; use lamb's wool between toes if moist
• Apply lanolin cream or lotion to prevent cracking; wear cotton/natural fibre socks
• Wear white socks to identify drainage or bleeding quickly
• Ideal footwear: soft leather, adjustable lacing/straps, wide toe box
• Never use corn/callous removers (risk of self-injury with insensate skin)
• Routine nail care: straight transverse cuts; referral to podiatrist if unable to perform safely
• Never test water temperature with insensate feet - use elbow or intact skin

• Assess and recommend appropriate footwear
• Moulded or extra-depth shoes for deformed feet
• Custom insoles for pressure redistribution
• Referral to orthotist/podiatrist as part of MDT

Upper Limb Sensory Loss:

• Visual compensation for hand tasks (looking at what hands are doing)
• Protective gloves for cooking and workshop tasks
• Adapted tools with textured handles for grip feedback
• Temperature-safe equipment (oven mitts, insulated cups)

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5.2 OT for Peripheral Neuropathy (Motor Deficit)

• Ankle-foot orthosis (AFO) prescription and training
• Gait training with adaptive ambulation device
• Home safety assessment - remove trip hazards, improve lighting

• ROM exercises for finger and wrist joints
• Strengthening exercises for intrinsic hand muscles
• Splinting for functional support (wrist cock-up splint, thumb spica)
• Adaptive equipment with built-up handles to compensate for reduced grip
• Assistive devices for fine motor tasks (button hooks, elastic laces, jar openers)

• Wrist neutral night splint to reduce nocturnal CTS symptoms
• Activity modification - avoid sustained wrist flexion/extension
• Tool handle adaptations to reduce vibration and force
• Referral for surgical decompression if conservative management fails

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5.3 OT for Diabetic Retinopathy / Low Vision

• Blood glucose monitoring: Large-display glucometers, talking glucometers, braille-labelled devices, audio insulin dosing guides
• Insulin administration: Insulin pen magnifiers, pre-filled dose devices, auto-injectors; syringe loading aids; talking insulin pens
• Medication management: Large-print labels, medication organisers (dosette boxes), pill dispensers with auditory reminders
• Reading food labels / nutrition: Magnifiers, screen-reading apps, large-print resources

• Contrast enhancement in the home (light switches on dark walls, contrasting crockery)
• Improved lighting in work and cooking areas
• Large-print clocks, phones, and appliances
• Screen-reader software for computer and phone use
• Referral to low-vision specialist and ophthalmologist
• Mobility and orientation training (if vision severely reduced)

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5.4 OT for Diabetes Self-Management Education (DSME)

"Ways to improve the patient's knowledge, skills, and abilities necessary for diabetes self-care, emphasising psychosocial issues and emotional well-being."

• OT assesses functional capacity to perform self-management tasks (not just knowledge)
• OT identifies performance barriers (motor, sensory, cognitive, environmental)
• OT adapts self-management tools and techniques to individual patient capacity

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5.5 OT for Diabetic Foot Ulcers and Wound Care

• Pressure off-loading - total contact casting, MCR footwear, crutch training, wheelchair provision
• Activity modification during healing - which activities are safe vs. contraindicated
• ADL adaptation around immobility/off-loading requirements
• Wound inspection education - teaching patient and family to inspect, clean, dress wounds
• Return to function - graduated weight-bearing after healing
• Prevention of recurrence - permanent footwear changes, activity habits

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5.6 OT in Post-Amputation Rehabilitation

"Because most amputations are performed for complications of diabetes or vascular disease, patients may have secondary complicating factors that affect therapy, such as sensory deficits, kidney disease, cardiovascular disease, chronic infection, respiratory disease, and arthritis. Other factors influencing function and safe performance of ADL are impaired vision and memory deficits."

• Residual limb care and shaping (bandaging, positioning, oedema management)
• Bed mobility, transfers, wheelchair skills
• ADL retraining using one-limb techniques
• Psychological adjustment to amputation and body image

• Prosthesis donning and doffing
• Progressive ambulation and stair training (with PT)
• ADL retraining with prosthesis
• Home assessment and modification
• Return to work assessment

• Community mobility
• Driving assessment (bilateral lower limb amputees - hand controls)
• Leisure and vocational reintegration

• Bilateral amputations are more common (other limb at risk)
• Comorbidities (visual impairment, neuropathy in remaining limb) affect prosthetic use
• Cognitive issues may impair prosthetic training
• Emotional response to amputation + grief over chronic disease trajectory

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5.7 OT for Autonomic Neuropathy - Falls Prevention

• Educate on rising slowly from lying to sitting to standing (dangle at bedside)
• Monitor BP in lying, sitting, and standing before discharge activities
• Elastic compression stockings
• Bed rails and grab rails for safe position changes
• Timing of activities relative to meals (post-prandial hypotension risk)
• Remove trip hazards from home

• Balance training activities
• Safe footwear advice
• Home modification (clear pathways, adequate lighting, handrails on stairs)
• Walking aids if needed

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5.8 OT for Psychological Complications

• Screening: PHQ-9 for depression, PAID scale for diabetes distress
• Lifestyle Redesign® programme - evidence-based OT intervention; studies show improvements in HbA1c, self-management behaviours, mental health, and physical function
• Occupational goal setting - identifying meaningful occupations to motivate self-management
• Habit and routine modification - restructuring daily routines to embed self-management
• Role adaptation - adjusting roles to accommodate diabetes demands without abandoning valued activities
• Motivational interviewing - facilitating behaviour change for lifestyle modification
• Group-based programs - peer support, shared problem-solving, normalisation
• Cognitive-behavioral approaches - challenging self-blame, catastrophising, avoidance
• Caregiver and family involvement - shared decision-making, reducing burden of sole responsibility

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5.9 OT in Lifestyle Modification

• Physical activity as occupation - identify meaningful activity contexts (gardening, swimming, walking groups) rather than prescribing generic exercise
• Meal preparation - kitchen assessment and adaptation; cooking skills for healthy eating; label reading
• Sleep hygiene - sleep patterns are intrinsically linked to metabolic health and diabetes self-management
• Weight management - activity planning, occupational balance
• Smoking cessation - as part of risk reduction education

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5.10 OT for Work Rehabilitation

• Neuropathy, vision loss, and fatigue affect specific work tasks
• Hypoglycaemia episodes create safety risks in certain jobs
• Dialysis schedules create inflexibility

• Functional capacity evaluation - identifying work abilities and limitations
• Workstation adaptation - magnification equipment, ergonomic modifications for hand impairment
• Work schedule modification - accommodating medication/meal/monitoring routines at work
• Employer education - hypoglycaemia management in the workplace
• Return-to-work planning after amputation or hospitalisation

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6. SUMMARY: OT INTERVENTION BY COMPLICATION

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7. OT PRECAUTIONS IN DIABETES

1. Hypoglycaemia during activity - always have glucose tablets available; know patient's blood glucose before activity; stop if symptoms develop (shakiness, confusion, sweating, pallor)
2. Avoid activity with blood glucose >250-300 mg/dL (hyperglycaemia increases infection risk, impairs wound healing, and may indicate ketoacidosis)
3. No barefoot walking or unprotected foot exposure - insensate foot = silent injury risk
4. Temperature caution - no hot water/paraffin on insensate feet; test water with intact skin
5. Orthostatic hypotension awareness - always supervise position changes
6. Sternal precautions if post-CABG surgery (common in diabetic patients)
7. Fragile skin and slow wound healing - inspect contact areas of splints and orthotics at every session
8. Renal clearance - patients on dialysis have complex medication schedules; fatigue is profound on dialysis days; schedule OT on non-dialysis days where possible
9. Cardiovascular monitoring - exercise parameters (HR, BP, SpO2) during activity as per cardiac precautions
10. Cognitive impairment - diabetes is a risk factor for dementia; cognitive screen may be needed to determine capacity to learn and retain self-management skills

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8. FRAMES OF REFERENCE IN DIABETIC OT

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9. RELEVANT REFERENCE BOOKS FROM YOUR LIST

Books 9 and 10 (pediatric OT) are not directly applicable to adult diabetes complications. However, pediatric diabetes (Type 1 DM in children) is a relevant application for Case-Smith and Kramer/Hinojosa - the OT role includes supporting children with diabetes in school settings, self-injection training, and family education, which would be found in those texts.

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Sources used: Harrison's Principles of Internal Medicine 22E (2025) (/textbooks/9781265977061/); Campbell's Operative Orthopaedics 15th Ed 2026 (/textbooks/9780443117633/); Goldman-Cecil Medicine (/textbooks/9780323930345/); Robbins & Kumar Basic Pathology; Morgan & Mikhail's Clinical Anesthesiology; Mulholland & Greenfield's Surgery 7e; Radomski - OT for Physical Dysfunction (tnaiota.org); Primary Care OT: A Quick Reference Guide (2023); OT Toolkit - Diabetes References; Sokol-McKay D, AOTA - Occupational Therapy's Role in Diabetes Self-Management (2011).

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Occupational Therapy in Geriatric Conditions

Comprehensive Research Notes

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1. UNDERSTANDING GERIATRIC CONDITIONS - Foundation for OT Practice

Key Geriatric Syndromes Relevant to OT

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2. COMPREHENSIVE GERIATRIC ASSESSMENT (CGA) AND OT

"Ideally, the CGA is conducted over several visits, in the home and in the clinic, by a variety of health care professionals in addition to the physician, including nursing, physiotherapy, occupational therapy, and social workers." (Brenner and Rector's The Kidney, /textbooks/9780323532655/)

CGA Domains and OT Contribution

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3. OT ASSESSMENT TOOLS IN GERIATRIC PRACTICE

A. ADL/IADL Assessment Tools

• Barthel Index (BI) - 10-item ADL assessment; widely used in inpatient settings
• Katz Index of Independence in ADL - classic 6-item assessment (bathing, dressing, toileting, transferring, continence, feeding)
• Functional Independence Measure (FIM) - 18-item; motor and cognitive domains; most comprehensive
• Lawton-Brody IADL Scale - 8 IADL domains (telephone, shopping, cooking, housekeeping, laundry, transport, medications, finances)
• Canadian Occupational Performance Measure (COPM) - client-centred goal identification across self-care, productivity, leisure

B. Cognitive and Perceptual Assessments

• Mini-Cog - rapid screening (3-item recall + clock drawing); high sensitivity/specificity
• Montreal Cognitive Assessment (MoCA) - 30-point; screens multiple cognitive domains
• Mini-Mental State Examination (MMSE) - classic 30-point; widely used
• Clinical Dementia Rating (CDR) - integrates cognitive, functional, and social-cognitive items
• Allen Cognitive Level Screen (ACLS) - OT-specific; assesses cognitive capacity for activity performance
• Rivermead Behavioural Memory Test - functional memory assessment

C. Falls and Balance Assessment

• Berg Balance Scale (BBS) - 14-item balance performance test
• Tinetti Performance-Oriented Mobility Assessment (POMA/Tinetti) - gait and balance
• Timed Up and Go (TUG) - mobility, balance, functional gait; >12 seconds = fall risk
• Dynamic Gait Index (DGI) - gait during functional tasks
• Functional Reach Test - balance during functional reaching
• Duke Mobility Protocol

D. Psychological Assessment

• Geriatric Depression Scale (GDS) - 15 or 30-item; validated for older adults
• PHQ-9 - depression screening
• GAD-7 - anxiety screening
• PAID - for diabetes-related distress in older adults with DM

E. Environmental Assessment

• Home Falls and Accidents Screening Tool (HomeFAST)
• Westmead Home Safety Assessment
• Safety Assessment of Function and the Environment for Rehabilitation (SAFER)
• Structured Observation of Activity in Living (SOAL) - community mobility

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4. OBJECTIVES OF OCCUPATIONAL THERAPY IN GERIATRIC CONDITIONS

Primary OT Objectives:

1. Maintain and maximise functional independence in ADL and IADL for as long as possible
2. Prevent functional decline through early intervention and rehabilitation
3. Prevent falls and fall-related injuries through multifactorial intervention
4. Enable "ageing in place" - supporting older adults to remain in their own homes safely
5. Promote cognitive function and delay dementia progression through cognitive and occupational engagement
6. Manage and prevent delirium during hospitalisation through non-pharmacological strategies
7. Provide adaptive equipment and home modifications to compensate for functional limitations
8. Support carers and family in providing safe, enabling care
9. Address psychosocial well-being - depression, social isolation, loss of roles
10. Facilitate community participation and meaningful occupation in later life
11. Support palliative and end-of-life care when appropriate
12. Collaborate with MDT in comprehensive geriatric assessment and management

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5. OT INTERVENTIONS BY GERIATRIC CONDITION

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5.1 Falls Prevention - Core Geriatric OT Role

Multifactorial Falls Assessment (OT Component):

• Intrinsic factors: Balance, gait, muscle strength, vision, hearing, cognition, medication side effects, orthostatic hypotension, foot problems
• Extrinsic factors: Home hazards, footwear, lighting, floor surfaces, furniture height
• Behavioural factors: Fear of falling, risk-taking behaviours, rushing, carrying items while walking

OT Interventions for Falls Prevention:

• Remove mats and throw rugs (48% of homes - most common recommendation)
• Change footwear to well-fitting, non-slip shoes
• Install non-slip bathmat in wet areas
• Install grab rails in bathroom, toilet, and stairs
• Improve lighting throughout the home (especially stairs, hallways, bedroom-to-toilet path)
• Install night lights for nocturnal toileting
• Secure or remove loose electrical cables
• Lower bed height to safe transfer level
• Raise toilet seat height
• Move frequently used items to accessible levels (between hip and shoulder height)
• Remove clutter from walkways
• Ensure telephone is accessible to avoid rushing

• Functional balance activities during ADL practice
• Seated and standing exercises graded for individual capacity
• Tai chi and gentle yoga (strong evidence for falls reduction)
• Weighted activities for upper and lower limb strengthening
• Proprioceptive training through graded surfaces and challenges

• Walking aids: cane, quad cane, rollator frame, standard frame
• Training in safe technique for stairs, outdoor surfaces, curbs
• Wheelchair prescription if mobility severely limited
• Hip protector pads prescription for osteoporosis

• Fear of falling creates a vicious cycle: fear → inactivity → deconditioning → greater fall risk
• Graded exposure to feared activities
• Cognitive-behavioral approaches to catastrophic thinking about falls
• OT-led group programs (e.g., Stepping On program - evidence-based OT group fall prevention)

• Vision: Referral to ophthalmologist; adequate lighting; remove bifocals on stairs; contrast enhancement
• Hearing: Hearing aid fitting; clear communication in environment
• Proprioception: Appropriate footwear; contrast flooring at level changes

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5.2 Functional Decline and ADL Retraining

ADL Hierarchy in Geriatrics (Goldman-Cecil - reverse order of acquisition/loss):

• Children first learn to feed → dress → work
• People with dementia first lose ability to work (advanced ADL/IADL) → dress → feed
• OT targets the earliest level of decline to prevent cascade

OT Approach to Functional Decline:

1. Restorative approach - retraining skills lost to acute illness (post-hospitalisation)
2. Compensatory approach - adaptive equipment and modified methods when restoration is not possible
3. Environmental modification - adapting the environment to support remaining function
4. Carer training - educating family and care workers in enabling approaches (not doing for, but with)

ADL Retraining Areas:

IADL Support:

• Meal preparation: Kitchen adaptation, stool at work surface, microwave vs. stove, ready meals for low-function days
• Medication management: Dosette boxes, blister packs, medication reminder apps, large-print labels
• Home management: Laborsaving devices, energy conservation (4 P's), delegation of heavy tasks
• Finances: Online banking, direct debits, referral to social services
• Community access: Transport options, community bus, disability concessions, scooter assessment

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5.3 Dementia - OT Throughout the Disease Trajectory

"A person with dementia may first lose the ability to work, later to dress, and later to feed." (Goldman-Cecil Medicine, /textbooks/9780323930345/)

OT in Mild Dementia (IADL affected; ADL largely preserved):

• Cognitive rehabilitation: Errorless learning, spaced retrieval, memory aids
• Daily routine structuring: Written schedules, white boards, visual cues, labelled cupboards
• Task simplification: Breaking complex IADL into single, cued steps
• Safety assessment: Stove safety (automatic gas cut-off, induction hob), medication security, financial safeguards
• Driving assessment: Cognitive and functional driving evaluation; referral to occupational therapist driving assessor
• Technology: GPS trackers, falls alarm pendants, automated medication dispensers, simplified phones
• Community participation: Maintaining valued roles and meaningful occupation for as long as possible
• Carer education: Teaching communication strategies, simplifying instructions, enabling remaining abilities

OT in Moderate Dementia (ADL affected):

• ADL retraining with errorless learning: Structured, cued ADL routines
• Behavioural interventions: Activity-based approaches to manage behavioural and psychological symptoms of dementia (BPSD) - agitation, wandering, sundowning
• Meaningful activity prescription: Reminiscence activities, craft, music, gardening - matched to premorbid interests
• Environmental modification: Safe wandering paths, door alarms, colour coding of toilets, removal of hazards
• Carer training and support: Practical ADL assistance techniques; respite options; carer stress management

OT in Severe Dementia (Basic ADL affected - feeding, continence):

• Feeding support: Adaptive crockery and cutlery; seating positioning for safe swallowing; finger foods; assessment for dysphagia in coordination with SLT
• Comfort and dignity: Positioning, pressure care, sensory activities (hand massage, music)
• Palliative OT: Quality of life, comfort, meaningful sensory engagement, family support

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5.4 Delirium Prevention and Management

"Nonpharmacologic delirium prevention protocols have been shown to reduce the incidence of delirium. The most widely used strategy is a multicomponent nonpharmacologic approach... occupational therapy is part of the multidisciplinary delirium prevention team." (Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Miller's Anesthesia, /textbooks/9780323935920/)

OT Role in Delirium Prevention (Hospital Inpatient):

• Orientation: Regular orientation to person, place, time; familiar objects from home; photographs
• Meaningful activity: Cognitive activities (reading, word games, reminiscence) to maintain engagement
• Early mobilisation: Get patient out of bed and engaged in self-care activities; prevents deconditioning
• Sleep-wake cycle preservation: Daytime activity; limit night-time disturbance; avoid daytime napping
• Sensory aids: Ensure hearing aids and glasses are in place and working
• Hydration and nutrition support: Prompting and assisting with eating and drinking
• Family involvement: Family presence and familiar voices/stimulation

OT Role During Delirium Episode:

• Calm, reassuring, consistent approach
• Reduce environmental stimulation (noise, light)
• Re-orientation without confrontation
• Simple, clear, one-step instructions
• Maintain familiar routines where possible
• Ensure safe environment (bed rails, removal of trip hazards)

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5.5 Frailty and Prehabilitation

"Frailty remains a potentially modifiable risk factor. Preoperative rehabilitation programs have been introduced to reduce frailty and improve surgical outcomes." (Miller's Anesthesia, /textbooks/9780323935920/)

OT in Frailty Management:

• Prehabilitation: Pre-operative OT assessment and intervention to maximise function before elective surgery
• Functional assessment: FIM, Barthel, TUG to baseline functional status
• Graded activity: Progressive, purposeful activity to build physical reserve
• Nutrition-activity interface: Mealtime support to improve nutritional intake fuelling activity
• Preventing hospital-associated disability: Early mobilisation, ADL engagement during admission
• Discharge planning: Comprehensive home assessment, carer support, community services

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5.6 Hip Fracture Rehabilitation

"Hip Fracture Care pathways with early mobilization targets, delirium screening and prevention protocols, interdisciplinary rounds (physiotherapy, occupational therapy, nursing)." (WHO Benchmarks for Equitable Hip Fracture Care, /textbooks/1008/)

OT in Hip Fracture Rehabilitation (3 Phases):

• Bed mobility training, safe positioning
• Seated self-care activities (grooming, dressing upper body)
• Hip precautions education (posterior approach: no hip flexion >90°, no adduction, no internal rotation)
• Provision of adaptive equipment: raised toilet seat, toilet grab frame, long-handled shoe horn, sock aid, dressing stick, reacher
• Delirium monitoring and prevention activities

• Progressive ADL retraining within hip precautions
• Home assessment (pre-discharge or early post-discharge home visit)
• Kitchen function assessment and modification
• Stair assessment and training
• Adaptive equipment trial and provision
• Community mobility planning

• Full home modification implementation
• Community access and transport
• Falls prevention program (to prevent second hip fracture)
• Return to leisure and meaningful occupation
• Social engagement to prevent isolation and depression

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5.7 Depression and Psychosocial Well-being

• Occupational engagement as antidepressant: Evidence consistently shows that meaningful activity reduces depressive symptoms in older adults
• Role maintenance/resumption: Identify lost roles (worker, grandparent, volunteer, gardener) and facilitate re-engagement
• Social participation: Group OT activities; community clubs; intergenerational programs
• Reminiscence therapy: Using past occupation memories and activities for identity and meaning
• Activity scheduling: Behavioural activation - scheduling pleasurable activities daily
• Motivational interviewing: Addressing motivational deficit (low motivation is a core depression symptom)
• Grief counselling support: Loss of function, independence, spouse, home - referred to psychology or counselling

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5.8 Sensory Impairment in Older Adults

• Vision: Environmental contrast enhancement; improved lighting; magnifiers; large-print materials; adaptive devices (see diabetes/low vision section); referral to ophthalmologist
• Hearing: Hearing aid fitting and use training; FM systems; visual alert systems (doorbell/phone flashers); communication strategies; reduce background noise during activities
• Proprioception: Balance training, appropriate footwear, visual compensation strategies

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5.9 Cognitive and Perceptual Rehabilitation

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5.10 Occupational Engagement, Leisure, and Social Participation

• Leisure assessment: Identifying premorbid interests and abilities still possible
• Activity adaptation: Modifying gardening, crafts, music, sport to accommodate physical limitations
• Intergenerational activities: Linking older adults with younger family members and community groups
• Technology: Tablets, computers, video calling (Zoom, FaceTime) for social connection
• Community mobility: Transport assessment, community confidence building
• Volunteering and giving: Maintaining sense of purpose and contribution
• Spiritual engagement: Supporting attendance at religious/spiritual activities

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5.11 Carer and Family Education

• Training family in safe ADL assistance techniques (safe guarding, not doing for)
• Transfer and moving techniques (hoist, transfer belt)
• Communication strategies for dementia
• Recognising signs of carer stress and burnout; referral to carer support
• Educating on enablement philosophy (supporting independence vs. creating dependence)
• Discharge planning with family involvement

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5.12 Palliative Care OT in Older Adults

• Meaningful occupation: Identifying what matters most to the patient in remaining time
• ADL comfort: Minimising distress during personal care
• Positioning and pressure care: Comfort positioning, pressure mattress prescription
• Legacy activities: Memory books, recording life stories, letters to grandchildren
• Carer support: Preparing family for caring role; grief support
• Dying in preferred place of care: Home assessment to enable preferred death at home

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6. SETTINGS FOR GERIATRIC OT

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7. OT PRECAUTIONS IN GERIATRIC PRACTICE

1. Fall risk at all times - always clear walkways; supervise ambulation; ensure appropriate footwear during sessions
2. Orthostatic hypotension - dangle before standing; monitor BP in position changes; particularly after meals and medication
3. Cognitive fluctuation - adapt session length and demands to patient's best cognitive time of day (often morning)
4. Polypharmacy effects - sedation, dizziness, extrapyramidal effects; note medication changes that affect function
5. Hip precautions post-surgery - strict adherence; do not exceed precaution limits during any ADL activity
6. Skin fragility - inspect all contact areas of equipment and splints; avoid pressure from hard equipment edges
7. Nutrition and hydration - ensure patient has eaten and is hydrated before demanding activity sessions
8. Delirium fluctuation - do not confuse delirium with dementia; always assess cognition at start of session; modify session if patient confused
9. Pain - uncontrolled pain is a major barrier to participation; assess and address before activity
10. Carer and elder abuse awareness - observe relationship dynamics; mandatory reporting obligations

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8. FRAMES OF REFERENCE IN GERIATRIC OT

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9. RELEVANT REFERENCE BOOKS FROM YOUR LIST

Books 9 and 10 (pediatric OT) are not applicable to geriatric conditions in adults.

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10. SUMMARY TABLE: OT ROLE IN GERIATRIC CONDITIONS

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Sources used: Goldman-Cecil Medicine International Edition (/textbooks/9780323930345/); Kaplan & Sadock's Comprehensive Textbook of Psychiatry (/textbooks/9781975175733/); Miller's Anesthesia 10e (/textbooks/9780323935920/); WHO Benchmarks for Equitable Hip Fracture Care (/textbooks/1008/); Brenner & Rector's The Kidney (/textbooks/9780323532655/); NCAHP Draft OT Curriculum; MDPI OT Systematic Review - Fall Prevention in Older Adults (2024); Academia.edu - OT Role in Fall Prevention for Community-Dwelling Older Adults.

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Occupational Therapy in Chronic Obstructive Pulmonary Disease (COPD)

Comprehensive Research Notes

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1. UNDERSTANDING COPD - Foundation for OT Practice

• Emphysema - destruction of alveolar walls → loss of elastic recoil → air trapping
• Chronic bronchitis - chronic productive cough for ≥3 months in ≥2 consecutive years
• Small airways disease - narrowing of bronchioles

Aetiology

• Tobacco smoking - principal cause (~80% of cases)
• Occupational exposures (dust, fumes, chemicals)
• Biomass fuel exposure (indoor cooking smoke in low-income countries)
• Alpha-1 antitrypsin deficiency (genetic)
• Recurrent respiratory infections in childhood

Pathophysiology Relevant to OT

• Airflow limitation → increased work of breathing → dyspnoea on exertion
• Dynamic hyperinflation - air trapping during exercise worsens breathlessness
• Respiratory muscle weakness - diaphragm flattened by hyperinflation; accessory muscles overloaded
• Peripheral muscle weakness - deconditioning, systemic inflammation, malnutrition
• Hypoxaemia - reduced oxygen delivery to exercising muscles → early fatigue
• Hypercapnia (in severe COPD) - carbon dioxide retention; somnolence

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2. CLINICAL FEATURES DIRECTLY RELEVANT TO OT

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3. GOLD STAGING OF COPD (Clinical Reference for OT Activity Grading)

Validated Symptom Assessment Tools (OT-relevant):

• CAT (COPD Assessment Test) - 8-item health status measure; includes home activity limitation, confidence leaving home, sleep, energy (Harrison's 22E)
• mMRC (Modified Medical Research Council) Dyspnoea Scale - grades breathlessness 0-4 during activities
• BODE Index - Body mass index, airflow Obstruction, Dyspnoea, Exercise capacity (6MWT) - prognostic indicator

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4. MULTIDISCIPLINARY TEAM IN PULMONARY REHABILITATION

"Comprehensive pulmonary rehabilitation programs typically include education, instruction in respiratory and chest physiotherapy, psychosocial support, and exercise training."

• Pulmonologist / respiratory physician (programme director)
• Occupational therapist - ADL retraining, energy conservation, adaptive equipment, psychosocial support
• Physiotherapist - exercise training, breathing physiotherapy, secretion clearance
• Nurse - education, medication management, monitoring
• Respiratory therapist - oxygen equipment, nebuliser use, inhaler technique
• Dietitian - nutritional assessment and support
• Psychologist/counsellor - anxiety and depression management
• Social worker - community support, benefits, housing

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5. OBJECTIVES OF OCCUPATIONAL THERAPY IN COPD

Primary OT Objectives:

1. Reduce dyspnoea during ADL and IADL - the central goal of OT in COPD
2. Teach and apply energy conservation techniques to maximise functional performance
3. Integrate breathing techniques into daily activities to control breathlessness
4. Train and retrain ADL/IADL performance with adapted techniques and equipment
5. Assess and modify the home environment to reduce energy demands and fall risk
6. Prescribe and train in use of adaptive equipment and assistive devices
7. Manage psychological impact - anxiety, depression, fear of breathlessness, activity avoidance
8. Support return to meaningful occupation - work, leisure, social participation
9. Educate patient and family in self-management and symptom monitoring
10. Facilitate oxygen therapy management - safe use, equipment handling, portability

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6. OT ASSESSMENT IN COPD

6.1 Occupational Profile

• Prior level of function and meaningful occupations
• Current ADL/IADL capacity and what has been abandoned due to breathlessness
• Roles, routines, work, leisure, social participation
• Home environment - layout, stairs, bathroom, kitchen
• Carer/family situation

6.2 Dyspnoea Assessment during ADL

"A frequently employed means of evaluating the performance of patients in their ADLs is to ask them to mime their activities, performing them as if they were at home, without interference by the examiner. During the performance, the examiner observes: time taken, body position adopted, and changes in dyspnoea, heart rate, and oxygen saturation by pulse oximetry." (Jornal Brasileiro de Pneumologia - OT/COPD energy conservation review)

• Dyspnoea rating: Modified Borg Scale (0-10) or mMRC before and during activity
• Heart rate (HR): Before and during activity
• Oxygen saturation (SpO2): Pulse oximetry continuously during activity
• Respiratory rate (RR)
• Time to complete task
• Body posture and positions adopted
• Techniques used vs. optimal technique

6.3 Standardised Assessment Tools

• Modified Borg Dyspnoea Scale - 0-10; subjective breathlessness during activity
• 6-Minute Walk Test (6MWT) - functional exercise capacity; SpO2, HR, dyspnoea monitored
• FIM (Functional Independence Measure) - ADL independence
• Canadian Occupational Performance Measure (COPM) - client-centred goal identification
• CAT (COPD Assessment Test) - includes activity and participation domains
• Fatigue Severity Scale (FSS) - fatigue impact on functioning
• PHQ-9 / GAD-7 - depression and anxiety screening
• Home Falls Assessment Tools - falls risk from COPD-related deconditioning

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7. OT INTERVENTIONS IN COPD

7.1 Energy Conservation - Central OT Intervention

"Energy conservation techniques are tools used in pulmonary rehabilitation programs with the aim of reducing energy expenditure of patients with COPD during ADL, decreasing sensation of dyspnoea, increasing functional performance and improving quality of life." (Jornal Brasileiro de Pneumologia)

The Five P's of Energy Conservation (COPD-adapted):

Specific ADL ECT Applications:

• Seated shower using shower chair/stool (reduces standing energy cost)
• Tepid (not hot) water - hot water increases ventilatory demand
• Handheld showerhead
• Long-handled bath sponge/brush to avoid bending
• Terry cloth dressing gown instead of towelling dry (saves energy)
• Rest seated after bathing before dressing

• Sit to dress and undress - all items
• Lay clothes out before starting
• Dress lower body first (most demanding)
• Exhale while bending for socks and shoes
• Long-handled shoe horn and sock aid to avoid bending/breath-holding
• Loose, front-fastening clothing; Velcro fasteners
• Avoid tight-waisted clothing (restricts diaphragm)

• Seated at vanity; elbow support on surface (reduces arm-elevation respiratory demand)
• Electric toothbrush, razor (reduces effort)
• Rest arms between tasks

• Sit on a high stool at counter level
• Prepare in advance (batch cooking, microwave use)
• Use lightweight pots and utensils
• Slide items along surfaces rather than lifting and carrying
• Electric appliances (food processor, electric can opener)
• Rest during cooking (use timer so patient can sit)

• Delegate heavy tasks (vacuuming, heavy lifting)
• Use a wheeled trolley instead of carrying
• Ironing: seated, in short periods
• Laundry: front-loading washing machine; avoid overhead clothes line

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7.2 Breathing Techniques Integrated into ADL

"Pulmonary rehabilitation typically includes instruction in breathing techniques such as diaphragmatic and pursed lips breathing - aimed at helping patients relieve and control breathlessness, improve ventilatory pattern, prevent dynamic airway compression." (Fishman's Pulmonary Diseases and Disorders, /textbooks/9781260473940/)

A. Pursed-Lip Breathing (PLB)

• Technique: Inhale slowly through nose (2 counts); exhale slowly through pursed lips as if blowing out a candle (4-6 counts; 2:1 or 1:2 ratio of inspiration:expiration)
• Mechanism: Creates back-pressure preventing airway collapse; reduces respiratory rate; increases tidal volume; reduces dynamic hyperinflation
• OT application: Teach patient to use PLB during ANY exertion - walking, climbing stairs, bending, carrying
• "Breathe out on exertion" - exhale (through pursed lips) during the effortful phase of each movement

B. Diaphragmatic Breathing (Abdominal Breathing)

• Technique: Place one hand on chest and one on abdomen; breathe so that abdomen rises more than chest; slow, deep breaths
• Mechanism: Improves efficiency of ventilation; reduces use of accessory muscles; reduces oxygen cost of breathing
• OT application: First taught at rest (patient lying, then sitting, then standing), then integrated during activity performance
• Training sequence (per Jornal Brasileiro de Pneumologia):
  1. At rest - supine/sitting; acquires perception of respiratory movements
  2. During light activity with upper limb support (brushing teeth, combing hair - seated with elbow support)
  3. During seated activities without upper limb support
  4. During standing activities
  5. During walking and functional tasks

C. Inspiratory Muscle Training (IMT)

• Threshold device used by physiotherapy and OT
• Strengthens inspiratory muscles
• Reduces dyspnoea perception during activity

D. Controlled Breathing during Exertion

• Stair climbing: Inhale on flat step → exhale (PLB) while climbing step → pause if needed
• Rising from chair: Inhale → exhale while pushing up
• Carrying: Exhale on the lift; use trolley; carry close to body
• Reaching: Exhale while reaching; avoid breath-holding (Valsalva)

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7.3 ADL and IADL Retraining

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7.4 Home Assessment and Environmental Modification

• Bedroom: Move bedroom to ground floor if stairs cause severe dyspnoea; hospital bed if positioning required
• Bathroom: Shower chair/stool, grab rails, handheld shower, non-slip mat, raised toilet seat
• Kitchen: Stool at worktop, reorganise frequently used items to accessible height, remove overhead storage demands
• Living area: Chair at right height with armrests (facilitates rising); remove trip hazards
• Stair management: Stairlift assessment if stairs are a significant barrier; rails on both sides
• Oxygen equipment storage: Safe storage of oxygen cylinders; fire safety education (no smoking near oxygen)
• Ventilation: Ensure good air circulation; fan provision (handheld fan directed at face reduces dyspnoea perception - evidence-based)

• Directing a handheld fan at the face stimulates facial receptors → reduces perception of dyspnoea
• OT prescribes and trains use of handheld fans as a simple, low-cost, evidence-based breathlessness management strategy

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7.5 Adaptive Equipment and Assistive Devices

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7.6 Psychosocial Intervention

• Depression: 10-57% prevalence in COPD (Murray & Nadel, /textbooks/9780323655873/)
• Anxiety: 7-50% prevalence; panic disorders much more common in COPD than general population (Kaplan & Sadock)
• Over 40% of patients with COPD suffer from depressive symptoms - COPD is strongly associated with depression and anxiety (Kaplan & Sadock, /textbooks/9781975175733/)

• Activity-based graded exposure: Systematic re-introduction of avoided activities to break the avoidance cycle
• Breathlessness desensitisation: Controlled exposure to activity-induced breathlessness with supported breathing techniques
• Cognitive-behavioral approaches: Challenging catastrophic thoughts about breathlessness ("I'm dying" → "This is uncomfortable but safe if I use my techniques")
• Relaxation training: Progressive muscle relaxation, guided imagery, mindfulness - reduce anxiety and accessory muscle tension
• Panic management: Emergency breathlessness management plan - positions, PLB, fan, rescue inhaler, when to call for help
• Activity scheduling: Rebuilding meaningful daily routine to reduce depression
• Peer support: Group pulmonary rehabilitation provides social normalisation
• Role and identity work: Supporting patient in maintaining valued roles despite COPD limitations

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7.7 Exercise Training (OT Component in Pulmonary Rehabilitation)

"Exercise training provides an ideal opportunity for patients to learn their capacity for physical work and use and practice methods for controlling dyspnoea. Resistive training can lead to significant increases in muscle strength important for many ADLs."

• Activity analysis: Identifying the metabolic demands of specific daily activities
• Purposeful activity as exercise: Gardening, cooking, craft - graded for intensity
• Upper limb training: Critical for ADL (arm elevation worsens dyspnoea in COPD - accessory muscles shared between arm elevation and breathing)
  • Supported arm exercises (elbows on table): less dyspnoea
  • Unsupported arm exercises: more demanding; gradually progressed
• Lower limb training: Walking programs are first choice; cycling, hydrotherapy
• Resistive/strength training: Important for ADL muscle strength
• Oxygen use during exercise: OT coordinates with respiratory therapist on supplemental O2 use during activity sessions when SpO2 drops during exertion

• Benefits specific to muscles/tasks trained - so train in the activities the patient does
• Walking programs particularly valuable - also improve social participation
• Emphasise endurance over maximal intensity - endurance changes more than peak exercise and improve function within limits
• Use Borg RPE scale (target 4-6/10 "somewhat severe breathlessness") rather than heart rate targets

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7.8 Secretion Management (OT Component)

• Positioning for postural drainage: OT positions patient to facilitate gravity-assisted drainage of specific lung segments before activity
• Active Cycle of Breathing Technique (ACBT): OT teaches and monitors technique during ADL routines
• Huffing technique (forced expiration technique): More effective and less tiring than coughing
• Timing of clearance relative to activity: Clear secretions before demanding ADL to optimise breathing capacity during the activity

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7.9 Oxygen Therapy Management

"Handling equipment is particularly difficult for physically disabled and frail patients. Therefore, it is important to assess each person's oxygen needs and provide appropriate instruction."

• Assessment of patient's ability to handle oxygen equipment safely
• Training in safe use, donning/doffing of nasal prongs, oxygen concentrator operation
• Portable oxygen system selection and training (liquid O2 vs. concentrator vs. cylinder)
• Integration of O2 into ADL routines (activity pacing with and without supplemental O2)
• Fire safety education (no smoking, no open flames near O2)
• Community participation with portable O2 - driving assessment, travel planning, restaurant visits

• Stop activity if SpO2 drops below 88% (typical COPD threshold; individual targets set by physician)
• Aim for SpO2 ≥92% during activity where possible
• Adjust activity intensity and use supplemental O2 to maintain safe SpO2

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7.10 Self-Management Education

• Understanding COPD: disease process, symptoms, triggers
• Energy conservation and pacing principles
• Breathing techniques and when to use them
• Inhaler and nebuliser technique (in coordination with respiratory nurse)
• Oxygen equipment use (if prescribed)
• Activity planning and scheduling
• Recognising exacerbation warning signs
• Emergency action plan (what to do when breathlessness suddenly worsens)
• Smoking cessation support (if still smoking)
• Nutrition and weight management (both underweight and overweight worsen COPD)
• Sleep hygiene (nocturnal hypoxaemia, sleep positioning)
• Travel advice (altitude, airline O2, carrying medications)

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7.11 Work and Vocational Rehabilitation

• Work capacity evaluation using METs and activity analysis
• Workstation modification - seated work, reduced physical demands
• Exposure reduction - avoid dust, fumes, cold air, known triggers
• Pacing at work - rest breaks, activity scheduling
• Employer liaison - reasonable adjustments
• Return-to-work planning after acute exacerbation hospitalisation

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8. COPD AND THE UPPER LIMB - A KEY OT FOCUS

• Shoulder girdle muscles (trapezius, SCM, scaleni) serve dual function as accessory respiratory muscles AND arm elevators
• When arms are raised, these muscles cannot assist breathing → dyspnoea spikes
• Forward lean with arm support (on walker, table) offloads these muscles → relieves dyspnoea

• ALL grooming, dressing, and cooking techniques modified to minimise sustained arm elevation
• Arm support strategy: Keep elbows close to body or resting on surface during grooming
• Avoid "chicken wing" posture - arms raised out to side increases dyspnoea
• Electric grooming aids eliminate sustained arm elevation
• Wheeled walker with arm rests - allows forward lean and arm support while walking

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9. PHASES OF PULMONARY REHABILITATION AND OT

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10. PRECAUTIONS AND CONTRAINDICATIONS TO OT ACTIVITY

• SpO2 drops below 88% (or physician-specified threshold)
• HR exceeds prescribed maximum or drops from exertion
• Moderate-severe chest pain
• Marked increase in dyspnoea beyond expected
• Confusion or dizziness
• Cyanosis (blue lips/fingertips)

1. Always have pulse oximeter during activity sessions
2. Ensure supplemental O2 available if prescribed
3. Ensure rescue inhaler (SABA) is accessible before activity
4. Avoid activity during acute COPD exacerbation - rest, maintain vital functions
5. Avoid extreme temperatures (cold air and hot humid conditions worsen dyspnoea)
6. Avoid isometric exercise and Valsalva manoeuvre
7. Never rush the patient - pacing is therapeutic
8. Avoid strong odours (perfume, chemicals) which can trigger bronchospasm
9. Falls precautions - COPD patients have 46% higher fall risk (deconditioning + dyspnoea-related avoidance)
10. Psychological sensitivity - do not push through breathlessness anxiety; validate the experience

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11. OUTCOMES AND EVIDENCE BASE

"Pulmonary rehabilitation is an established effective management strategy for people with COPD that improves functional and maximal exercise capacity and health-related quality of life. It also effectively alleviates dyspnoea and fatigue, enhances the sense of [well-being]."

• Energy conservation techniques (ECTs): Significantly lower oxygen uptake and dyspnoea perception during ADL in trained vs. untrained patients (Velloso & Jardim)
• Post-PR functional improvement: Patients perform daily activities using lower percentage of their maximum cardiopulmonary capacity → less fatigue and breathlessness
• OT-specific evidence: Studies document that systematic OT integration in pulmonary rehabilitation improves ADL performance, reduces dyspnoea during activities, and improves quality of life (Atheneum Narrative Review 2024)

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12. FRAMES OF REFERENCE IN COPD OT

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13. RELEVANT REFERENCE BOOKS FROM YOUR LIST

Books 9 and 10 (pediatric OT) are not directly applicable to adult COPD. However, principles of activity grading and breathlessness management in paediatric asthma may have limited overlap with Case-Smith and Kramer/Hinojosa texts.

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Sources used: Fishman's Pulmonary Diseases and Disorders, 2-Volume Set (/textbooks/9781260473940/); Murray & Nadel's Textbook of Respiratory Medicine (/textbooks/9780323655873/); Harrison's Principles of Internal Medicine 22E (2025) (/textbooks/9781265977061/); Kaplan & Sadock's Comprehensive Textbook of Psychiatry (/textbooks/9781975175733/); Vreka & Georgiou - "Breathing Strategies as OT Interventions in COPD: A Narrative Review", University of Western Macedonia; Jornal Brasileiro de Pneumologia - "Functionality of COPD Patients: Energy Conservation Techniques"; Whittington NHS - OT COPD Breathlessness Factsheet; PMC - Effectiveness of ECTs in COPD patients, Karger 2020.