VR Consumers with Medical Disabilities

1. VR Consumers with Medical Disabilities • Decision Making and Planning • Strategies for Counselors Dr. Kevin Horan Rehabilitation Psychologist Consultant:Navajo OSERS

2. Outline of Presentation 1. Type of Disability (brief overview) 2.Trait/Symptoms of Condition 3.Recommendations For VR Planning 4.Top Possible Job Placements 5.Feedback ------>Discussion

3. Ten Common and Uncommon Medical Conditions seen in VR Consumers 1. Back Injury 2. Diabeties 3. Epilepsy 4. Spinal Cord Injury 5. Heart/Lung Conditions 6. Pain Syndromes 7. Thyroid Conditions 8. AIDS 9. Hand-Arm-Shoulder injury 10. Multi System Breakdown

4. Back Injury • Herniated Lumbar Disc • Spongy Material Seperating each Vertebra. • Body extrudes through protective covering • Degenerative Disc Disease • Narrowing of Disc Space • Bony Spur Development • Spinal Stenosis • Narrowing of Space in Spinal Canal (Acquired or Congenital) • Fracture • end plate injury due to lifting,carrying, etc. • Osteoporosis • Loss of Bone Mass • Typical (women over 40)

5. Treatments • Typical Surgery • Laminectomy (Remove bony arches of one or more Vertebra to relieve compression of the spinal cord) • Spinal Fusion (Stabilize spinal section with a bone graft or Synthetic Device)

6. Other Treatments • Epidural Blocks • TENS Unit • Medication • Pain Management Clinic • Brace Devices • Chiropracter • Work Hardening • Traditional • (ie. Bone Doctor)

7. Traits Observed in Consumers with Back Injury • Loss of Income, Bills, Family Stress • Non Productive = Guilt = Depression • Pain Medication = Tolerance=Confused/ Cognitive Changes • Pain = Frustration + Temper = Conflicts in Family • Difficulty Accepting Limitations • Transferable Skills in areas not Compatible with Disablity • Downtime - Long Delay after putting in Job applications = Depression + FT =Low Confidence Levels • Vocational Interests are often Unrealistic • Idle Time may lead to Drinking(Self Med) -Time Cycle off • Limited Strength and Stamina • Occasional Remarkable Recovery/Presentation

8. Recommendations 1. Use prevention measures (ie.Back Brace) 2. Avoid Discrimination During Job Search 3. Avoid Pain Medication Trap 4. Counselor Make Discomfort Apprasial 5. Be Aware of Unrealistic Rate of Recovery 6. Determine Current Point of Stability 7. Be Aware of Financial Incentives 8. Help Consumer Realize Functional Limits/Restrictions in relation to Vocational Objectives 9.Be Aware of Potential for Long Term System Breakdown

9. Top 10 Jobs (Back injury) • Building Inspector • Appraiser of Home • Transportation Jobs -with modifications • Light Duty Clerical/Computer Operation • Small Bench Work Repair • Cashier With Adaptations • (Home Maker Companion)-Prep Meals for Others • Telemarketing Phone Sales/Retail Sales/Car Sales • Intake Worker-Health Info Tech • Teacher-Teaching Aide Positions

10. DX= Blood after fasting overnight sugar greater then=140 Mg/dl on two separate occasions. Increase in thirst, hunger, and urination Diabetes Mellitus 10 million Americans have diabetes but fewer then half are DX Pancreas does Not secrete enough Insulin or cells of body become resistant to Insulin= Blood sugar can not get to cells Type 1 = Type 2 = Insulin Dependent (Usually in children Adolesence) Non Insulin Dependent (usualy onset after 35-40) 10% 90% Related Genetic Factor Enviromental Factor Obesity Onions and Garlic Lower Blood sugar

11. Traits Often Observed in Diabetic VR Consumer • May need to frequently urinate • May have numbness or start of neuropathy • Could be dizzy or weak-non healing cuts • May show stress/frustration and depression • Desire to stay in old line or previous work • Poor adjustment to extreme work change • May be unrealistic-May deny limitations • Self medicate with ETOH-at risk for D coma • May not understand complications of diabetic process and balance of body systems • Family often acts as best option to motivate and maintain compliance in consumer

12. Recommendations • Maintain-Monitor ----> • Weight factor • Blood sugar monitor (Hba1c) • Long term complications awareness • Job choice must be short(hrs) with (breaks) • Post Dx Problems could impact plans • Find out time since being Dx and comp level • Avoid future jobs that may require vision tests • Avoid very hot work environments • Periodic updated physical and visual exams

13. Top 10 Jobs For Consumers With Diabetes 1. Telemarketing Jobs 2. Light Duty Housekeeping 3. Health Information Technician 4. Kindney Dialysis Technician 5. Nutritionist - Educator 6. Teachers Aide 7. Inventory Work - Retail Outlets 8. Appraisor - Estimation Work 9. Motor Vehicle Worker (clerical) 10. Banking Jobs - Legal aide - Interpreter

14. Epilepsy Sympotomatic = Known Cause A group of neurological conditions characterized by recurrent episodes of convulsive seizures,sensory disturbance,abnormal behavior or loss of consciousness Idiopathic = Unknown cause Main Causes Head Trauma, Intracranial Infection, Poison, Brain Tumor, Vascluar Disturbance, Intoxiction Continued->

15. Absence = Sudden momentary loss of consciousness Former name Petit Mal Focal = Abnormal electrical discharge in localized part of brain. Usually near motor sensory strip Tonic-Clonic = Generalized Involuntary muscular contractions and change in respiration followed by T+C spasms of muscles ie. Grand Mal Types of Seizures Psychomotor = Temporary loss of consciousness, Loss of judgement, Automatic behaviorisms and possible abnormal acts-hallucinations, Deja Vu, Temporal Lobe Disease or Injury Meds = Reduce Seizure Threshold Stabilize Cell Membrane = Decrease Intracellular Sodium and Excitability of Eleptogenic Focus

16. Some Traits Observed in Consumers with Epilepsy 1. Memory concerns (short term) 2. Appearance may be altered (dilantin-gums-scars) 3.Quick temper or anger- some may not show this 4. Loss of confidence due to seizures in public 5. Denial of disability’s impact on day to day life 6. Frustrated due to transportation limits 7. Non compliance with medication 8. Dependence on family/Possible overprotection 9. Transferable skills often in noncompatible area 10. Substance abuse resulting in seizures 11. Many consumers with epilepsy may be very well adjusted

17. Epilepsy Recommendationss 1. Encourage compliance with medication, diet, drinking and general doctors orders - be aware of individual aura 2. Discourage job placements in work enviroments that are potentially dangerous (ie driving, cooking, heavy equipment) 3. Keep seizure log - if seizures are still occuring, show the log to your doctor to help adjust medication 4. Discuss if the consumer is operating a motor vehicle and has not been seizure free for a year 5. Be aware of the possibility of concurrent depression and frusturation in the consumer 6.Be aware of the possibility of self medication with ETOH or drugs due to adjustment problems 7.Recommend supportive counseling if you detect emotional, behavioral, or family problems Continued-->

18. 8.Provide additional vocational counseling if the consumer is choosing unrealistic jobs not compatable with a seizure condition 9.Look closely for memory problems that might interfere with job or daily living Top Ten Jobs Laundry work Upholstry Clerical Tile Layer Computer operation Telephone Cashier Receptionist Auto part Salvage Food Vendor Top Ten Jobs

19. Spinal Cord Injury 33 Vertebra- 7 cervical, 12 thoracic, 5 lumbar 5 sacral Sci - Complete or Incomplete c+first t=Quad below T 1 = Para 10,000 + new SCI Injuries a year 20% falls 15% sports/rec 15% gunshots, stabbings, industrial, etc. Majority =Young active men Voc + Predictors = Young age, high education positive attitude and ability to drive Voc Interest -Still like working with things rather then people or data Changes = Sensation, Motor Control, Sexual Functioning, Regulation of Internal Temperature, Blood Pressure, Bowel + Bladder Processes, Onset of Pain, Spasticity, Decubiti (pressure sores) Ulcers Cognitive Level usually normal but 16% Para +TBI Premorbid = Normal to Impulsive/Rebellious Non conformity Continued-->

20. Profile = Possibly More Depression - 45% -Symptoms of Anxiety, Anger, Fear, Low Self Esteem Pain = 44% to the point it interferes with ADL’s Suicide = Slightly more common then general public but still infrequent ISDB = 62% ETOH, Drugs, Refusing Treatment, Prolonged Sitting = sores Divorce = (25% - pre + post injury) some studies show less divorce after SCI Family = No problem raising a family Cultural = Swiss Para’s - 77% working- 67% driving - 25% higher ed Nigerian= Most Para’s dead within a year

21. Spinal Cord Injury Traits 1.May show decubiti ulcers/urinary tract infections/ Breathing Problems/Muscle Spasms that could be a factor in job development/treatment 2. Hidden Depression - feeling helpless/angry/guilty 3. Family and Financial Issues may emerge 4. Social Changes-Isolation less in Public eye 5. Transportation concerns- adaptation of vehicle 6. Development of Dependency 7. Hidden Substance Abuse Concerns 8. Concern over upgrading wheel chairs 9. Sexual Issues may be present in some cases 10. Occasional Excellent Adaptations to SCI

22. Recommendations 1. Concurrent PT-OT. Assistive Technology Evals may be needed 2. Review need for adaptative equipment in home - Possible work adaptation 3. Possible need to refer for Independent Living consultation 4. Review time since injury (new-late-later) to assess adaptation and VR needs 5. Recommend ongoing health education to adapt to SCI 6. Counseling may be an individual and/or family need 7. Determine if any ongoing legal issues need to be resolved prior to VR plan 8. Determine if individual can be re-employed in previous position with accomodations or job site modifications 9. Prioritize driving or mobility needs and implement non-costly plan Continued-->

23. Top 10 Jobs (SCI) • Cashier • Banking Positions • Bench work • Counselors • Education/Teacher • Computer operation • Clerical Jobs • Self employment • Dispatcher • Broadcasting

24. Heart Disease Primary Heart Conditions • Congestive heart failure= Heart can not pump enough blood possibly due to prolonged high blood pressure, previous heart attack, faulty valve, heart muscle problems,chronic lung disease(ie.Asthma) • Symptoms - Weakness, Fatigue, Shortness of Breath • Arrhythmias = Disturbance in the Rhythm of Heart beat Some symptoms mild (no problem) Others are dangerous • Ventricular Tachycardia - Rapid uncontrolled contractions of Heart • Cardiomyopathy = Disease of Heart Muscle or structure Less Force/Contractions= Less blood circulation can cause Toxic, Viral, Degenerative Conditions

25. Mitral Valve Prolapse = Loss of Tone or Deformitity of Heart Valve which can cause leakage or heart murmer • Atherosclerosis - Buildup of Plaque/ Cholesterol/Fatty Material or Debris in the inner layers of the walls of medium and large arteries

26. Lung Disease • Asthma - Respiratory Disorder recurring Dyspnea, Weezing, Problems breathing due to constriction of the bronchi causing much coughing - excessive mucous possibly precipitated by inhaling of allergens, pollution, exercise, stress , etc • Emphysema = Destructive changes in lung walls - Loss of Elasticity, Decreased gas exchange Causes = Chronic Smoking - Old Age • Bronchitis = Acute or Chronic inflammation of the mucus membranes or Tracheobronchial tree Caused by Viral Infection Continued-->

27. Chronic Bronchitis = Excessive Secretion of Mucus for 3 months over 2 sucessive years (Cig smoking/Air pollution) • Chronic Obstructive Pulmonary Disease or COPD = A Progressive Irreversible Condition with Diminished Capacity of Lungs - Chronic Cough, Dyspnea, Aggrevated by Cig’s + Pollution.

28. Cardio/Pulmonary DisordersTraits seen in VR Consumers 1. Dyspnea - Shortness of breath - Deconditioned HBP 2. Poor Mobility - Limits in stair climbing/walking/standing 3. Tendency to keep smoking in spite of problems 4.Poor diet choices(ie.fast food)-little education related to nutrition 5. Overweight - Possible Obesity 6. Often trying for SSDI - Varied levels of Empowerment 7. Depression over health Problem + Functional limitations tendency to give up and be Passive 8. Turn control over to Doctor - Become External 9. Weakness - Often can not work Fulltime 10. Possible Mix of many medications from many Doctors

29. Recommendations 1. Physical Restoration including Diet, Exercise and Strength Building monitored by Health Professionals 2. Recommend Education regarding further Complications - Long term effects on Health 3. Be aware of Mood Changes particularly Depression 4. Need for Smoke Cessation Program- ie. Nicoret gum - patches zyban - hypnosis-etc. 5. Vocational Counseling to redirect to a more sedentary job but one that also requires some Phys+Mental Action 6. Wellness Center and Group Support 7. Involve Family in Plan but don’t let Consumer rely too much on others Encourage empowerment - Improve apperance Continued--> 8. Dietary/Nutritionist Consultation with family (read Ingredients)

30. 9. Don’t develop a bias just because of Consumers appearance(ie Over weight) -Encourage job possibility and Positive Factors Top Ten Jobs Clerical Fitness Center (front desk) Food Preparation Health Food Store Floral Arrangment Intake Workers Computers Custodial Cook-Hospital Nursery Top Ten Jobs

31. Pain • Unpleasant Experience associated with Tissue Damage or Disease Acute=Usually short duration with well defined cause Chronic=6 months or Longer Recucurring Acute= ie. Arthritis - Tumors • Estimated 75 million plus Americans have Chronic pain 40 million recurring Headaches 15 million Low Back Pain 100’s of thousands = cancer 20 million arthritis • Disability Payments = 10 times faster then the growth of the US Population Back injury = Well over a Billion yearly in Disabilty Funds • Problems = Political Medical Continued--> Economical Humanitarian Rehabilitation

32. Presentations will vary Significantly • Decreased level of Activity • Abuse of Medication (selective inactivity) • Excessive Over Utilization of Health Resources • Mental Status Change = Depression in 70% of Cases • Work Disability and Vocational Maladjustment

33. Traits in Pain Patients 1. Some may exaggerate pain - Some endure the pain- Look at pre morbid life style and personality traits 2. High levels of pain often result in frequent body change of position, irritation and possible depression 3. The family of Pain victims is also impacted by condition 4. Some people develop a pain identity that often gets reinforced 5. Some consumers have additional tolerance to pain medication 6. Cognitive decreases often co-exist with pain - due to medication or the effect of pain on the consumers functioning 7.Substance Abuse or self medication may also be a variable 8.Consumers show a decline in physical activity- Which may lead to other negative health problems Continued-->

34. 9.Secondary gain may be a factor impacting motivation or empowerment 10.Pain related disablities often result in consumer placing school or extended training above a more available job placement

35. Recs for consumers with Pain 1. Have all medication and psychological records available to review - use Consultants from medical field if necessary 2. Be aware of possible legal (ie. workers comp) or ongoing litigation which may impact motivation or outcome 3. Look for signs of pain medicine tolorance or abuse 4. Be aware of co existing physical conditions or substance abuse or other problems 5. Recommend - pain management or alternative methods to cope or aleviate pain- ie. (accupuncture, hypnosis, biofeedback) 6.Determine the acual motivation for seeking help- is the consumer serious about pursuing modified job placement options 7.Assess transferable skills for alternative non physically demanding or pain inducing job options Continued--> 8.Be very observant of physical signs of pain in consumer - estimate degree of time consumer can work

36. 9.Review background- is this a pattern or does the consumer have good work history? Top Ten Jobs Self employment (crafts) Computer (modified) Telephone Temp fill in Clerical (with breaks) Light duty driving Light duty schd. In home cook Cashier Elderly care Top Ten Jobs

37. Thyroid Hyper-May cause heart disturbance, insomnia, severe anxiety Thyroid is in front of neck below larynx-It regulates metabolism Greek word = shield Pituitary gland secretes hormone that stimulates thyroid (TSH) 1 to 4%of Population has moderate to severe hypothyroid condition 10 to 12% of Population has mild hypothyroid condition. Advanced age increases rate of hypothyroid more frequently in women Most common past cause of hypothyroid = Iodine deficiency T gland adds Iodine to Amino Acid Thyrosine to create hormones Iodine added to table salt - 1924 - Michigan population had 47% Thyroid problems before this Goiter = 200 million world wide Certain foods block iodine utilization = goitrogens including turnips, cabbage, mustard, soybeans, peanuts, pine nuts Hashimoto’s disease (most common form)= Antibodies are formed that bind to the Thyroid and prevent manufacture of sufficient levels of thyroid hormones Continued-->

38. Symptoms often seen in Thyroid Conditions Sensitivity to Cold - Tissue swelling found in hyper/hypo active thyroid Higher Cholesterol = (Triglyceride) Risk of Cardiovascular Disease Irregular heavy periods Nails thin and brittle Brain sensitive to low thyroid hormone levels First symptoms = Depression, Weakness, Fatigue Late signs = Difficulty concentrating Joint Stifness Treatment = Desiccated Thyroid or Synthetic Thyroid supplement

39. Traits periodically seen in VR Consumer/ Thyroid Conditions 1. Hypo- If poorly controlled - Overweight, Sluggish, Neck swelling, Often Depressed, Bulging eyes, sensitivity to cold 2. Hyper - If poorly controlled Thin - Anxious - Paranoid almost might suspect amphetamine abuse 3. If Un-DX - May be treated for alternative Physical Condition 4. Freq Job change and problems with co workers/supervision 5. Often left alone, divorced, may develop physical or psychological problems 6. Frequent cases seen on Reservation or in rural areas-Often VR Consumers may have lived near Uranium mines 7.Often can not loose weight in spite of diet and exercise 8.May miss a lot of work due to energy decline or changes in motivation 9.Mood Swings/Cognitive Changes Continued-->

40. Recommendations -VR Consumer’s with Thyroid Conditions • Ongoing monitoring of blood THS levels • Encourage med/diet compliance-Avoid etoh/cigs/caff. • Use transferrable skills from previous low stress jobs • Avoid Physically demanding work/exposure to x rays • Rec-Supportive counseling if emotional changes • Involve family/educate re. symptoms/treatment • If employed-use Employee Assistance programs • Encourage exercise and stamina building-ie.Exercise stimulates thyroid gland secretions and increases tissue sensitivity to thyroid hormones

41. TOP 10 JOBS-THYROID CONDITIONS 1.Dog/Pet Groomer 2.Floral Arranger 3.Cake Decorator 4.Secretarial 5.Driving Jobs 6.Maintence Man 7.Hotel/Motel Clerk 8.Teacher (Elementary) 9.Self Employed-ie.Office Cleaning 10.Plumbing/Trades

42. Acquired Immunodeficiency Syndrome (Aids) Discovered by Scientists in 1983 HIV = Human Immunodeficiency Virus = Lowers Body Immune System ARC = AID’s Related Complex = Tired, Night Sweats, Weight Loss, Yeast Infections AID’s caused by infection with Human Immunodeficiency Virus HIV does not kill --it cripples the Immune System Person may die from severe infections or cancer 1.Pneumonia CD4 (Helper Lymphocye) Count is less then 200 cells per micro-leiter 2. Kaposi’s Sarcoma - cancer of the blood vessel walls CD8 (% of helper cells) to total Lymphocytes - less then 14% 3.Meningitis Vectors = Sexual - Needles - Blood Transfusions Continued-->

43. HIV is not a Death Sentence but is very serious United Nations estimate over 40 million worldwide living with AID’s USA - AIDs # of Cumulative cases to the year 2000 765,559 442,882 Died AIDs - .3% or 2,337 Native Americans Trend is going up in the minority Populations AID’s Dementia Complex (ADC) - Neurological effect of brain inflammation in one third of AIDs patients Memory loss - Dementia = loss of cog functioning and possible destruction of neurons density- 40% lower then non AID’s cases

44. AIDS VR Consumer Traits 1. Usually Reserved - Quiet - Uncomfortable 2. Possible Family Conflicts - Breech of Confidentiality 3. Low Physical Stamina -Frequently Tired 4. Unable to Continue at Previous Job but may try to stay at it 5. Usually a Lack of Education related to the Condition but Basic Treatment is Maintained 6. Quiet, Often Isolated, and Depressed, Out of Place - Limited Support 7.Many are Gay and maintain lifestyle but others are Heterosexuals-- All must deal with Stigma and Gossip 8.Marriage strained - Family divided 9.Often will Relocate back to the Res when diagnosed but then will Re-Relocate when support falters 10.Concurrent concern over substance abuse and reckless or risky behaviors or impulsivity in some cases

45. Recs for AID’s VR Consumers 1. Feasibly Issue with Supervisors needs to be reconciled -possibly with medical consultation 2.Can present job be modified or is not suitable given dianosis ? 3.Find support group- treat priorities with Confidentiality - Does Consumer feel comfortable with it - ie. AID’s- Sponser ? 4.Determine the level of family acceptance, is it genuine or problematic? 5.Employ Traditional Healing Services - try to avoid placing in a job that requires Health Dept., Food Prep, ect. 6.Consult a Nutritionist for possible Diet Modification 7.Consider Mental Health issues including: fear, depression, anxiety,frustration, etc. 8.Use alternative sources for rehabilitation- ie. immune building, healing services, Prayer, imagery,etc. 9.Insist on Medical Compliance with Treatments Continued-->

46. Top Ten Jobs Acountant Drivers Law /Professional Factory - Assembly Administrative Sales Secretarial Self employment Arts- Creative Casino jobs Top Ten Jobs

47. Arm/Hand or Shoulder InjuryINTRODUCTION Brachial Plexus Injury(Nerve damage = muscles-skin of arm) resulting inPain andlimited movement use of arm Compartment SyndromeArterial Compression + Reduction of blood supplySwelling and restricted movement with possible severe painwhich could cause permanent contractive deformity of the hand Carpal Tunnel SyndromeDisorder of the wrist and handCompression of the median nerve causing tingling, numbness, and painwhich could radiate to forearm and or shouldersDecreases in Strength and Dexterity

48. Elbow Joint InjuryCarpenters ElbowOveruse/Arthritic changes /pain Claw handExtreme Flexion/Hyperextension caused by Atrophy of Muscles ArthritisInflamation of joints swelling pain OsteoarthritisNon inflammitory joints degenerate - loss of cartillage,development of bone spurs Rheumatiod ArthritisChronic inflamatory deformaty/ collagen disease - swelling joints / pain

49. Hand-Arm-Shoulder Injury Traits In VR Consumers 1. Often seen in trades, labor, secretarial and cashier jobs 2.Chronic pain may be evident with concurrent irritation-headaches stress, depression,and discomfort 3.May be taking pain medication to excess resulting in additional problems ie (emotional or behavioral) 4.Rehab plan may be interupted due to a pending surgery - medical consults - etc 5.Confusion over doctors prognosis, release for work, workers compensation involvement,appointment dates, etc. 6.Uncertain regarding alternative work or training options 7.Often will be in denial and will pursue previous jobs in spite of injury and functional limits 8.Unaware of compounding problems such as arthritis, restricted ROM (Range of Motion),med side effects, etc. Continued-->

50. 9.Secondary gain may be a concern (ie. impending trial or settlement) 10.Schedule is thrown off - used to working hard and usually has high work ethic making inactivity more debilitating