Self Care & Activities of Daily Living

1. Self Care &Activities of Daily Living Sara Houlihan, PT, DPT UMHS

2. Wound Management Self Care Assistive & Adaptive Devices Work/Play/School Physical and Electrotherapy Agents

3. Review of Common Surgeries/Procedures • CABG: sternotomy incisions (no push/pull, lifting over 10#, full ROM to pain tolerance, use both arms at same time, “harvest site”-typically leg) • Heart Valve Repair or Replacement: thoracotomy=side of the body • TAVR: value replacement through femoral artery • Transplants • Heart • Lung: clam shell incision (across diaphram) • Pacemaker: one arm in sling for 24hrs, 90dg restriction to allow leads to be still and have scar tissue (4-6weeks) • Heart Catheterization: Femoral: L cath. R Subclavian: R cath. Radial Artery: B cath. (2-6hrs bed rest) • Amputations: watch opposite limb to protect and maintain.

4. Post Operative PT • Exercises

6. Post Operative PT Cont. • Walking program • Part of Cardiac Rehab • Begins post op day 1-2 • Goal is 30 minutes of ambulation, 4-6 days/week • Mall, HomeDepot

7. Wound Management • Precautions and Contraindications to movement • Prone Best, so fine flat with C-PAP • Universal Precautions • Trach care: clean and dry around site • Prevention of equipment skin breakdown Oxygen cannula on nose and ears (foam) Positioning: shoulder ROM Bed W/C: cushions, extenders

8. Incisions • Never pull in direction that pulls incision apart • Wait until scar fully forms prior to using friction or soft tissue techniques • Early soft tissue mobs uses a “tissue floating” method or “gentle milking” with compression

9. Post Operative Education • What is a MET level • Way to measure energy expenditures • Oxygen consumption measured in mL O2/kg/min • Applying to PT interventions • Activities have known MET levels associated with them

10. PT Interventions • ADL Training • Equipment Instruction • Issuing assistive devices • Return to Work Programs • Modalities

11. Home Evaluation • Accessibility • Entrance, handrails, distance of walkways, bathroom • Getting rid of hazards • Electrical cords in good condition and out of walkways • Smoke detectors, clear heating • Proper storage of flammables or chemicals • Make activities easier to perform • Appropriate lighting and passageways clear • Home modification • Emergency plans • Falls, Fire • Medication reactions, medical conditions • Family or friends to check on patient

12. BASIC ACTIVITIES OF DAILY LIVING BADL • Activities that are oriented toward taking care of one’s own body

13. Basic ADLs • Bathing, Showering-MET 1-2 • Clothing management • Transfer into and out of tub/shower • Performing cleaning activities of hair, body • Break Shower up: Hair, Upper body, Lower Body • Shower Chair, or a wand shower head • Dressing- MET 2 • Upper Body and Lower Body • Shirt, pants, belt • Under garments • Socks and Shoes • Personal Care • Personal Devices: Glasses, Hearing Aids • Personal Hygiene: Brushing Teeth, Nail care • Grooming: combing, brushing, styling, shaving

14. Basic ADLs • Sleep/Rest- MET 1 • Able to get in and out of bed • Able to perform bed mobility • Able to use positioning • Log Roll, can’t pull with arm >10# • Sexual Activity- MET 4-5 • Able to perform bed mobility • Able to use positioning • Up/Down Stairs

15. Instrumental ADLs • Simple Meal preparation and cleanup • Basic meal prep: sandwich, microwave dinner • Clean up paper • Complex Meal preparation and cleanup • Able to plan a meal and follow a recipe • Able to carry items in kitchen • Able to reach pots/pans, set-up of kitchen • Able to maintain safety • Able to wash dishes • Able to clean up surfaces/floor

16. Instrumental ADLs • Safety procedures and emergency responses • Able to attend to simple trauma • Able to recognize major illness • Able to respond to emergency • Able to recognize unsafe conditions • Shopping • Transfer in and out of car, no pulling • Able to withstand long distance community distances • Able to push, carry, reach • Use of a scooter

17. Instrumental ADLs • Care of others & Child rearing • Able to assist others • Able to participate in play or recreational activities • Able to physically assist • Able to transport to community • Care of pets • Able to feed, wash • Able to walk on leash, play, let outdoors • Able to transport to vet

18. Instrumental ADLs • Home Management • Able to clean house • Able to use washer/dryer (in basement) • Able to perform outdoor work • Financial management • Able to write for checks • Able to read and understand statements • Able to understand due dates • Able to calculate simple math • Health management and maintenance • Able to perform tasks required for health • Able to identify medical needs • Able to transport or drive to medical facility • Able to follow prescription directions

19. Assistive Devices • Parallel Bars (amputee) • Walkers • Standard (only if balance is impaired), Roll, 4 wheel with seat/brakes (need support when sitting), Hemiwalker • Crutches • Axillary, Lofstrand • Canes • Standard, SBQC, LBQC, hemicane

20. Assistive Devices • Reachers • Slings • Following pacemaker placement • Sock aids • Shoe horns

21. Assistive Devices • Physical Need • Safety • Energy • Energy Conservation • Assistance with breathing • Leaning forward • Tripod Breathing (abdominal contents drop, which helps drop more air into lungs)

22. Work/Play/Leisure • EDUCATION • Includes activities needed for being a student and participating in a learning environment • WORK • Includes activities needed of engaging in employment or volunteer activities • PLAY • Any spontaneous or organized activity that provides enjoyment, entertainment, amusement, or diversion • LEISURE • A nonobligatory activity that is intrinsically motivated and engaged in during discretionary time, that is, time not committed to occupations such as work, self-care, or sleep • SOCIAL PARTICIPATION • Activities associated with organized patterns of behavior that are characteristic and expected of an individual or an individual interacting within a given social system

23. ADA • Compliance • Civil Law, not a criminal act • Enforcement usually by fines • PTs can act as advocate and consultant • Handicap, Works Ergonomics • Workers Comp • Family Medical Leave Act: to help • Occupational Safety & Health Administration (OSHA)

24. ADA • Title 1- Employment • Have reasonable accommodations • Cannot discriminate due to disability • Title 2 - Public Service • Government Bldgs and Transportation • Title 3 – Public Accommodations • Accessibility: ramps, doors, stairs, elevators, signage • Title 4 – Telecommunications • TDD for HI; auditory for Blind • Title 5 – Misc Provisions

25. Work HardeningFunctional Capacity Evaluation

26. The guidelines serve the following purposes • For physical therapists - to design, implement and evaluate structured programs for injured workers. • For medical referral sources - to facilitate appropriate referral to structured programs. • For insurance companies, and managed care organizations - to develop appropriate methods of program authorization, monitoring and payment. • For Departments of Labor and Industry - to utilize as definitions and guidelines for worker compensation patients. • For managed care organizations, regulators, and providers - to serve as a resource documents. 

27. APTA Input • In 1991, the APTA established the Industrial Rehabilitation Advisory Council (IRAC) to classify the levels of work rehabilitation to accurately reflect contemporary practice, to standardize terminology and to address the needs of patients/clients, providers, regulators and payers.

28. APTA envisions multiple uses for these guidelines including: • Physical therapy services for injured workers • Physical therapist professional education programs • Professional development and staff education • Peer review • Education of legislators, employers, regulators and payers • Marketing

29. DEFINITIONS • Work Conditioning: an intensive, work-related, goal-oriented conditioning program designed specifically to restore systemic neuromusculoskeletal functions (e.g., joint integrity and mobility, muscle performance (including strength, power, and endurance), motor function (motor control and motor learning), range of motion (including muscle length), and cardiovascular/pulmonary functions (e.g. aerobic capacity/endurance, circulation, and ventilation and respiration/gas exchange).   The objective of the work conditioning program is to restore physical capacity and function to enable the patient/client to return to work. • Single PT, able to have endurance and strength for 6-8hr day • Work Conditioning Provider: A licensed physical therapist.   (APTA recognizes that other professionals may be Work Conditioning providers.)

30. DEFINITION • Work Hardening: a highly structured, goal-oriented, individualized intervention program designed to return the patient/client to work.   Work Hardening programs, which are multidisciplinary in nature, use real or simulated work activities designed to restore physical, behavioral, and vocational functions. Work Hardening addresses the issues of productivity, safety, physical tolerances, and worker behaviors. • Goal oriented, multidisciplinary

31. Definition • Work Hardening Providers: Work Hardening providers include the following professionals; physical therapists, occupational therapists, psychologists, and vocational specialists.

32. PROGRAM COMPARISON

33. PROGRAM CONTENT • Development of program goals in relation to job skills and job requirements • Interventions to improve strength, endurance, movement, flexibility, motor control and cardiovascular/pulmonary capacity related to the performance of work tasks • Practice, modification, and instruction in work related activities • Education related to safe job performance and injury prevention • Promotion of patient/client responsibility and self-management • Development of program goals and outcomes in relationship to specific job requirements • Interventions to develop joint integrity and mobility, motor function (motor control and motor learning), muscle performance (including strength, power, and endurance), range of motion, and cardiovascular/pulmonary capacity related to the performance of work tasks.

34. PROGRAM CONTENT Practice, modification, and instruction in simulated or real work activities Education related to safe job performance and injury prevention Provision of behavioral and vocational services as determined by the respective Work Hardening provider Promotion of patient/client responsibility and self-management Assist the patient/client to obtain as appropriate: Counseling for substance abuse. Engineering and ergonomic services Medical services Nutrition and weight control services Smoking cessation counseling

35. Occupational and Injury History Data: • Primary and secondary medical diagnoses • Diagnosis by physical therapist • Work status prior to injury • History of other treatment for this injury prior to entering the Work Conditioning or Work Hardening program, identifying all disciplines involved. • Date of injury • Same injury • New injury • Date Work Conditioning or Work Hardening program was initiated • Current and future employability • Time off work • Length of the program • Hours/day • Days/week • Total days

36. Discharge Data: • Total charges billed for the program • Program status (terminated or discharged) regarding return to work • Same employer or different employer • Previous job or different job • Full time or part time • Patient/client status at time of program termination/discharge • Referrals for additional services not available in the program • Payment source • Worker's compensation board • Private insurance

37. Functional Capacity Evaluations • Have to be trained to perform • Typically is 1-3 hours in length • Goal is to determine • What work set up is like • How to replicate work set up in clinic • If patient is able to and safe to complete physical demands of work situation • May be done at different points throughout physical therapy treatment

38. Functional Capacity Examinations • Measurements of function from an FCE • Compared to the physical demands of a job or other functional activities and predicts the potential to sustain these tasks over a defined time frame.  • Used to make return-to-work/activity decisions or disability determinations • Generate a rehabilitation plan. 

39. Functional Capacity Examination • Needs to have the following characteristics • Safety • Reliability • Validity • Practicality • Utility

40. The FCE provider Examination (includes history, systems review, and tests and measures) of the following systems: • Cardiovascular/pulmonary • Integumentary • Musculoskeletal • Neuromuscular • Administration of FCEs and interpretation of tests results. • Evaluation of physical demands of the workplace. • Identification of patient/client behaviors that interfere with physical performance. • Biomechanical components of safe work practices.

41. Physical Demand Characteristic Levels as listed in the Selected Characteristics of Occupations as Defined in the Revised Dictionary of Occupational Titles1 Categories of work demands are: • Sedentary • Light • Medium • Heavy • Very heavy The frequency of work demands are: • Never • Occasional • Frequent • Constant • Physical Demands of the Workplace

42. Examples of FCE • EPIC Lift • Polar Heart Rate Monitor • Purdue Pegboard • Minnesota Rate of Manipulation • Bennett Hand Tool Dexterity: bolts • Matheson SPOT Bench • Hand Spinal Function Sort • Spinal Function Sort • Jamar Hand Dynamometer • Push/Pull Sled

43. The Isernhagen Method for Functional Capacity Evaluation 1.Front carry correlates with horizontal lift 2.  Overhead lift correlates with overhead work 3.  Repetitive squat correlates to floor-to- waist lift 4.  Grip strength correlates to one handed carry

44. stair climbingstep ladder climbcoordinationpush (static)pull (static)right carryleft carryfront carryright hand gripleft hand griprotation standingrotation sittingbalancefloor-to-waist lift waist-to-overhead lift horizontal liftforward bending/standingforward bending/sitting elevated workrepetitive handingrepetitive fingeringcrouchingsittingstandingwalkingkneelingcrawling The Isernhagen Method for Functional Capacity Evaluation

45. The Isernhagen Method for Functional Capacity Evaluation • This method relies on • The therapist's expertise to determine maximum function by observing • The prime movers (muscles), Accessory muscles • Body mechanics, speed, gait • Heart rate and other physical factors • Rather than by the patient's • Report of pain, discomfort or observed pain behaviors. • The therapist determines when maximum effort has been reached and stops testing when the activity becomes unsafe and dysfunctional.  

46. Balancing Carrying Climbing Crawling Crouching Feeling Fingering Handling Kneeling Lifting Pulling Pushing Reaching Sitting Squatting Standing Stooping Walking Functional activities as defined by the Department of Labor may include, but are not limited to:

47. Ergonomics/Work Simulation • Science of modifying jobs to fit the capabilities of the people who do them. • Goal is to reduce work-related musculoskeletal disorders • Emphasis on safety, PPE • Ex: worklines, work stations, chairs, change work throughout day

48. Ergonomic Management • Job assessment • Musculoskeletal reporting and response system • Designated coordinator • Training • Encourage employee participation • Use of qualified personnel

49. How to Protect the Worker • Change positions often • Take a stretch break • Maintain neutral posture whenever possible • Eliminate or reduce musculoskeletal injury risk factors • Use of material handling aids • Report musculoskeletal injury symptoms

50. Physical and Electrotherapy • Mechanical Compressor • The Vest • Tilt table or standing table • Cardiac Chair • Biofeedback • Incentive Spirometry • Relaxation • Stimulation • Functional electrical stimulation