1. Understand the intergenerational concepts and the characteristics of each generation. How do
these characteristics influence their healthcare decisions?
Intergenerational concepts
● Traditionalist (1922-1945)
○ WWII, Great Depression, Greatest Generation, hoarders, loyal, polite, value tradition,
conformity, and very articulate.
● Baby Boomer (1946-1964)
○ Vietnam, Sexual Revolution, Hippie movement, very interactive, team players, like to work,
ambitious, value learning and education.
● Generation X (1965-1980)
○ Cold War, Gulf War, video games, music videos MTV, balance work, family & leisure.
○ Tech savvy, Balance between work, family, and leisure
● Millennial (Generation Y) (1981-1996)
○ 9/11, internet, smartphones, baby/ kid-centric, value recognition about achievement.
● Generation Z (1996-2010)
○ Zoomers, the first generation to grow up with the internet from a young age, digital natives,
social media
Stages of Aging
●
●
●
Young old (65-74)
○ newly retired or working, mor leisure time
○ manage chronic illness
Mild old (75-84)
○ modify role, simplify lives, need more rest, increased loss
Old old (85+)
○ reflect on meaning of life, peace vs. fear
○ systematic changes in: sensory system, motor system, cardiac system
○ rely on healthcare system, social programs
Adulthood
●
●
●
Early Adulthood (18-30)
○ Independence; beginning to make decision and commitments
○ Establish career goal, begin to accumulate property
○ Flexibility of thought
Middle Adulthood (30-60)
○ Beginning of decline in sensory & physical abilities
■ vision, reaction time & strength, change in hormone levels
○ Formation of families, career building, begin to be concerned with their legacy
Late adulthood (61+)
○ continued decline of senses, physiological changes, eval of one’s accomplishments
○ coping with change & loss, facing one’s own mortality
2. Review the domains of occupational therapy (AOTA 2014). All aspects of the domain transact to
support engagement, participation, and health.
OT’s domain: achieving health, well-being and participation in life through engagement in occupation
a) Client factors: values, beliefs, spirituality, body function, body structures
b) Performance patterns: habits, routines, roles, rituals
c) Performance skills: motor, process, & social interaction skills
d) Occupations: ADLs, IADLs, health management, rest & sleep, education, work, leisure, social
participation
e) Contexts: environment & personal factors
3. Understand the theoretical base of the biomechanical FOR as well as the primary assumptions.
Primary Assumptions:
1. Purposeful activity can be used to remediate loss of ROM, strength, and endurance. (Most activities
have a biomechanical dimension.)
2. If biomechanical deficits are remediated the person will automatically use these prerequisite skills to
regain functional skills. (People with biomechanical deficits have difficulty with occupational
performance.)
3. The body must be rested, then stressed (Biomechanical impairment can be corrected with modalities,
exercise, and repetitive activity.)
4. Best suited to individuals with an intact CNS. Underlying pathologies must be considered.
5. Bottom up approach- need to focus on the components to achieve the end results.
4. Why is the biomechanical FOR best for individuals with intact CNS?
Best for pts with intact CNS because they may have limited range, strength, and endurance, but have the
ability to perform smooth, isolated movements.
5. The biomechanical FOR looks at specific indicators of function vs. dysfunction such as ROM. What
are others? Structural stability (balance, positioning & control), ROM (passive/active), muscle strength (MMT),
peripheral edema, endurance
6. What is the rehabilitation FOR? Why do you need to take a top-down approach with clinical
reasoning within the rehabilitation FOR?
6. With compensation strategies, independence can be achieved when underlying impairments can not be
remediated.
7. A person’s level of motivation affects the extent to which an individual regains independence
8. Environments/the contexts in which a person performs influence his/her motivation for independence.
9. Rehabilitation involves a teaching-learning process. The client needs to have sufficient cognitive skills
to learn and to apply compensatory methods. Likewise, motivation enables a person to fully participate
in the teaching-learning process.
10. Top-down approach. It begins with the environment/context in which the individual will function, then
considers the individual’s goals (volition and habituation and current functional capabilities, and then to
the types of compensatory strategies needed to use these capabilities).
7. Remember that the rehabilitation FOR uses compensation strategies and/or adaptive devices to
maximize function
8. What types of evaluations allow the OT to find the indicators of function vs. dysfunction
● Mobility & ADL assessments look at function- is pt able to complete a task & how much assistance do
they need.
● From there, try to tease out where the dysfunction is. Might be a body structure or cognitive deficit.
○ You could do a 9HPT for coordination dysfunction or the MOCA for cognitive dysfunction.
● Assessments that assess structural stability (balance, positioning & control), ROM (passive/active),
muscle strength (MMT), peripheral edema, endurance
BALANCE
1. Review the charts describing static and dynamic sitting balance and static and dynamic standing in the lab
sheet from week 1. You will not be asked to write out the charts but may be given a patient example of
function and asked to state the functional balance grade.
● Assess pt’s static & dynamic sitting balance, and static & dynamic standing balance
Normal
Patient able to maintain steady balance without handhold support (static)
Patient accepts maximal challenge and can shift weight easily within full range of LOS in all directions
(dynamic).
Good
Patient able to maintain balance with handhold support; may require occasional minimal assistance (static).
Patient accepts minimal challenge; able to maintain balance while turning head/trunk
(dynamic).
Fair
Patient requires handhold support and moderate to maximal assistance to maintain position (static).
Patients unable to accept challenge or move without loss of balance (dynamic).
Poor
Patient unable to maintain balance.
2. For balance, know the postural vs. phasic muscles and which tend toward tightness and which toward
weakness.
● Postural (tonic) mm
○ Prone to tightness
○ Dynamic stabilizers of joints, keeps body upright
○ Higher resting tone than phasic mm on EMG
○ Atrophy less quickly than phasic mm
● Phasic mm
○ Responsible for movement, prone to weakness
○ Available on demand but not unconsciously responsive to pull of gravity
3. Describe the VOR and VSR reflexes and how they help control balance.
● Vestibular Ocular Reflex (VOR): Stabilize gaze during head movements to ensure good vision during
head motion, and moves eyes contrary to the head to stabilize line of sight
● Vestibular Spinal Reflex (VSR): Maintain posture & stabilized the body, reactions below the neck
4. Understand the difference between functional mobility and gait observations during an OT assessment
(informal) vs. standardized balance tests (Tinetti, FIST, TUG, MiniBESTest). You do not need to review the Berg
Balance.
● Informal Assessments
○ Functional mobility assesses bed mobility, transfer & gait, and W/C propulsion
○ Gait observation includes looking at gait speed, cadence, stride length, step length, step width
● Standardized Balance Tests
○ TUG: Fall risk assessment The Timed Up and Go Test (TUG) | Fall Risk Assessment
○ Tinetti POMA: Gait quality assessment Tinetti - Performance Oriented Mobility Assessment
○ Functional Reach: Assess stability contributing to fall risk Functional Reach Test
○
○
Function in Sitting (FIST): Assess pt’s dynamic sitting balance Sitting Balance Assessment
Mini BEST - Measures dynamic balance, functional mobility, & gait Mini BESTest Demonstration
FUNCTIONAL ASSESSMENT
1. What does CARE stand for in the CARE Item Set form? Remember that post-acute is any rehab
after the initial hospitalization and includes acute inpatient rehab, SNF, LTCH, and HH.
● Continuity Assessment Record and Evaluation (CARE)
2. What is the purpose of the CARE item set?
● To standardize assessment of patients' medical, functional, cognitive, and social support status
across acute and post-acute settings
3. Know the CARE item set codes 06-01 in their simplest terms, (i.e., partial/mod means that the
helper provides less than 50% assistance).
● Code 06: Independent - person completes activity independently, no assistance from helper
● Code 5: Set up or clean up assistance - Set up or clean up after activity. Helper can walk away
● Code 4: Supervision or touch A -assistance provided thru out activity (VC, steadying, CGA)
● Code 3: Partial/Mod A - Helper provides LESS THAN HALF the effort (lifts, holds, support trunk)
● Code 2: Substantial/Max A - Helper provides HALF the effort (holds trunk or limbs)
● Code 1: Dependent - Helper provides ALL the effort, pt does none
4. Review the specifics regarding what you need to assess for eating, oral hygiene, and toilet
hygiene. Also, be sure to understand what is meant by LE dressing vs. donning footwear as well
as bathing.
● Eating: ability to use suitable utensils to bring food/liquid to mouth & swallow once meal is
placed before pt.
○ Devices: built up utensils, thickening agents, plate guard
● Oral hygiene: ability to use suitable items to clean clean teeth & manage dentures (if
applicable)
○ Built up handle, suction brush, oral care swabs
● Toilet hygiene: Ability to maintain perineal hygiene, adjust clothes before & after BM, managing
ostomy (if applicable)
○ Devices: Toilet aid, grab bar, reacher
● LE Dressing: Ability to dress & undress above the waist including fasteners but NOT including
footwear (underwear, incontinence briefs, slacks). This includes orthotics & prosthetics (knee
brace, stump shrinker)
○ Devices: Dressing stick, reacher, button hook
● Footwear: Ability to put on & take off socks & shoes or other footwear appropriate for safety
including fasteners, & orthoses (boots, running shoes, AFO, elastic bandages, orthopedic
shoes)
○ Devices: Dressing stick, sock aid, LH shoe horn, elastic laces
● Shower/Bathe: Ability to bathe self, including washing/rinsing/drying self (NOT including
washing back & hair)
○ Parts: Both arms, chest, abdominal region, perineal area, buttocks, both upper & lower
legs
CLINICAL REASONING:
1. Understand the differences between the five types of clinical reasoning: Part of Ch. 8 (pgs. 123124), Documenting of Occupational Therapy Services in Pedretti.
a. Procedural reasoning: what is diagnosis, prognosis, complications, protocol for assessment &
intervention
b. interactive reasoning: exploring pt’s occupational needs, goals, concerns, & values, how does
disability fit into pt’s performance patterns (habits, role, routines)
c. Conditional reasoning: what contexts important to pt, intervention requires frequent
reappraisal of outcomes, what future can be imagined for client
d. Narrative reasoning: pt’s explanation of their life & disability, pt’s experiences, how does pt
experience their condition, OT uses therapeutic use of self
e. Pragmatic reasoning: demands of the setting, therapist expertise, pt’s social & financial
resources, pt’s potential discharge environment, what physical factors must be considered when
creating intervention plan, what are the therapist’s skill levels
VISION
1. Independence is threatened when vision falls below which number?
● 20/60
2. Know the bottom two levels of Warren’s visual perceptual hierarchy model
● attention = alert and attending
● oculomotor control, visual fields, visual acuity
3. Accommodation of the eye is its ability to change its focus from distant to near objects and is
achieved by the lens changing its shape. What are some reasons that accommodation can be
disrupted or decreased?
● cataracts, glaucoma, macular degeneration, diabetic retinopathy, neurological conditions,
trauma, surgery
4. What is convergence insufficiency?
● your eyes have trouble moving together to focus on objects close to your face
5. Know the general mechanism for developing macular degeneration, cataracts, glaucoma, and
diabetic retinopathy. Which one has scotoma as a characteristic?
● MD: age-related macular degeneration is an acquired retinal disorder caused by degenerative
changes in the retinal pigment epithelium with subsequent degeneration of the rods & cones
○ loss of central vision, increase need for light, glare sensitivity, Charles-Bonnet syndrome
(vision loss 7 how brain reacts to it)
○ central scotoma: visual disturbance & scotomas can vary from blurred gray spot to
dense blank spot
● Cataracts: opacification of the crystalline lens resulting in decreased visual acuity
○ glare sensitivity, decreased acuity & contrast sensitivity, increased myopia in nuclear
sclerotic cataracts
● Glaucoma: damage of optic nerve head, loss of central & peripheral vision, usually caused by
increased intraocular pressure
○ open angle glaucoma: no obstruction but damage to retina caused by intraocular
pressure
○ angle-closure glaucoma: obstruction of iris to pathway of aqueous humor
●
○ neovascular glaucoma: secondary disorder from other diseases (tumors, diabetes)
Diabetic retinopathy: results from vascular complication of both type I & II diabetes
○ both central & peripheral vision loss (swiss cheese)
○ floating spots, cloud vitreous fluid, poor contrast sensitivity & glare sensitivity
6. Why is it common to have visual problems after brain injury?
● Injuries can damage the eyes, muscles around the eyes or parts of the brain involved in vision:
○ cortical processing of visual information (primary & secondary visual cortex)
○ optical fields & neural/visual pathways
7. What are the four principles of low vision?
● Magnification:
○ higher the power of magnifier, the smaller the field of view (giving pt a magnifier is NOT
low vision rehab)
○ place magnifier on target & slowly bring it up to determine best focal length, MAKE IT
LARGER (large print)
● Lighting: elderly will need 3x amount of light as 20 year old; add lights to illuminate area
● Contrast: prints vs. solids, darker colored furniture, visual reminder w/ painters tape
● Position: viewing angle (eye level), ergonomics
8. Understand what is meant by a lighting assessment on slide 56
● Evaluate light conditions in a person’s environment to determine how they affect person’s daily
activities
● Where is the light, what kind of light is it, are there glares, what is their environment (floor,
steps)
9. When reviewing the end of the vision Pp, consider ways that contrast and lighting can be
incorporated into low vision rehab.
● Use bright, ambient lighting such as torchiere lamps to eliminate shadows
● Position lights & shades to minimize glare from reflective surfaces
● Sit with windows behind the individual
● Use solid colors and high contrast background for paper items
● Use large prints, labels, and organizers
SENSATION
1. What sensory dysfunction is more likely following a CNS injury vs. PNS injury?
● CNS injury: likely loss of proprioception or stereognosis; likely parietal lobe dysfunctions
● PNS injury: likely loss of touch pressure awareness & two-point discrimination
2. Name and define each of the forms of disturbances in sensation. Allodynia is a form of
dysesthesia where a patient feels exaggerated pain in response to any touch.
● Paresthesia: Tingling, electrical, or prickling sensation (Tinel’s sign or pins & needles)
● Hyperalgesia: Increased pain sensation (hypersensitivity w/ nerve regeneration)
● Dysesthesia: Unpleasant, abnormal sense of touch or discomfort from normal touch like clothe
● Allodynia: Type of dysesthesia, pain from non-painful stimulus like shingles
● Neuropathy: Dysfunction of PNS which results in impairment/loss of light touch > cold > heat >
pain sensation (in that order)
● Central pain: Caused by primary lesion or dysfunction in the CNS
3. You will not be asked to name ascending sensory tracts but you do need to know where each
type of sensory neuron decussates. What deficits would you expect to see above and below
the level of injury for a patient suffering from Brown-Sequard syndrome?
● Dorsal Column Medial Lemniscus (DCML) - decussates at brainstem
● Spinothalmic Tract - decussates at spinal cord level
● Brown-Sequard Syndrome - hemi section of the spinal cord, either left or right half
○ Above injury: No significant deficits???
○ Below injury: Ipsilateral LMN paralysis, loss of proprioception, discriminative touch,
vibratory sensation. Contralateral loss of pain, temperature, and non-discriminative touch
○ Note: Some touch may remain intact because crude touch is carried by multiple
pathways that go on both sides of the spinal cord.
4. During a sensory screening for a suspected PNS injury, the OT tests specific sites in order to
reflect larger portions of the hand innervated by the same nerve. What are the sites for the
Median, Ulnar, and Radial nerves?
● Median nerve - tip of thumb, index finger, middle finger, radial tip of ring finger
● Ulnar nerve - tip of small finger
● Radial nerve - dorsal thumb webspace
5. Understand the assessments for touch pressure and two-pt. discrimination using standardized
methods. Why do you use the Semmes Weinstein before 2-pt. discrimination?
● Touch pressure: Examines spectrum from light to deep touch pressure using Semmes
Weinstein Monofilament test
● Two Point Discrimination: Tests for receptor density using disk-criminator tool
● Semmes Weinstein Monofilaments are used first to determine pt’s baseline level of touch
sensitivity. This establishes if there’s any touch sensation present
6. Why would you use desensitization as a treatment for a patient and when would you do
protective sensory re-education?
● Desensitization: This method is used to elicit habituation for pt w/ hypersensitivity that limits
use of affected body parts.
● Protective Sensory Re-Education: This method is good for pt who lack protective sensation &
at risk for injury (ex: pt with decreased temperature sensation could be at risk for getting burned
while cooking)
7. Discriminative sensory re-education is appropriate if a patient has intact _______ sensation as
indicated by which monofilament? What are some examples of this treatment? The lab sheet
should help as a guide.
● Intact PROTECTIVE SENSATION as indicated by PURPLE pen (3.84-4.31 monofilament)
● Treatment examples: protect from sharp/cold/hot items, soften force used when gripping object,
built up handles to distribute gripping pressure, take breaks during activity, examine skin for
edema/redness/blisters
PAIN/EDEMA
1. Know the difference between acute and chronic pain, including non-specific pain.
● Acute pain is sudden and is commonly seen with an injury, surgery, disability, illness, trauma,
or other medical procedures
○ Usually serves as a warning of a disease/threat to the body
○ Pain is experienced for a short period of time (days to weeks)
○ Pain respond to medications and treatments
○ Sprains, cramping, headaches/migraines, stubbing a toe, etc.
● Chronic pain is recurring/persistent lasting for more than 3 months (12 weeks) and requires
additional treatment and care
○ Does not serve a biological purpose, is unpredictable and does not respond to traditional
treatments
○ Can significantly affect quality of life, mood, behaviors, routines, thoughts, attitudes, and
lifestyle choices
○ Leads to other symptoms including depression, insomnia, anxiety, and mood swings
○ Arthritis, cancer, neuropathy, autoimmune diseases
2. How much difference in volumetric reading between hands indicates a significant amount of
edema
● > 10 mL difference = edema
COORDINATION
1. Know the definitions from the week 3 lab sheet regarding coordination deficits
● Cerebellar ataxia: loss of muscle coordination as a result of cerebellar pathology
○ trouble initiating movement
● Diadochokinesis: inability to perform rapid alternating movements
● Dysmetria: overshooting/undershooting a target
● Dysarthria: incoordination of the speech mechanism
● Nystagmus: Involuntary movements of the eyeballs
2. Understand what type of coordination each of the 5 assessments evaluation: box and blocks,
Purdue pegboard, 9HPT, MDT, and functional dexterity test.
● Box and Block test: evaluates gross manual dexterity
● Purdue pegboard: evaluates finger manipulation, fine coordination, and assembly skills
● 9HPT: Test of finger and hand dexterity
● Minnesota manual dexterity test: designed to select personnel for semi-skilled operations
requiring coordinated arm/hand/finger movements
● Functional dexterity test: measures manual dexterity skills for functional fine motor
coordination task performance tests dynamic in hand manipulation and functional tripod grasp
3. Compare lengths of stay and service delivery for acute care hospitalization, acute inpatient
rehabilitation and skilled nursing facilities.
Setting
Acute Care Hospitalization
Length of Stay
Service Delivery
Days to 1-2 weeks
Daily
(d/c’d as soon as medically stable) OT initiates the rehab process,
makes recommendations, and
provides education/training to
patient and caregiver.
Acute Inpatient Rehab (postacute)
2-3 weeks, no longer than 4 weeks
Daily, pt must tolerate 3 hours a
day
Goal: discharge home
SNF (post-acute)
https://www.medicare.gov/coverag
e/skilled-nursing-facility-snf-care
Months to years
pt will not receive as much therapy
per day; usually 1 session of OT &
PT, SLP if indicated
4. When and how long does Medicare cover care in a SNF?
● SNF care is generally provided daily, on a short-term basis. Medicare covers up to 100 days of
care in a SNF, in a single benefit period, as long as you stay eligible.
BILLING AND PDPM:
1. Understand timed vs. untimed CPT codes and the 8-minute rule.
● Untimed codes - evaluation codes. You pick the complexity of the evaluations (Low, mod, high)
○ Differences needed for data
● Timed codes - Treatment codes. (self care, ther ex, therapeutic activity, neuromuscular reeducation, manual therapy)
● 8 minute rule - applies to time based codes. Be accurate, don’t round.
○ 8-22 minutes = 1 unit
○ 23-37 minutes = 2 units
● Used with mostly with outpatient
2. Understand what PDPM is and how it affects your patient.
● PDPM = patient driven payment model
● Used with SNF
● classifies patients into payment groups based on patient’s need & goals
3. Review the slide on productivity and understand how to calculate your productivity in an 8-hour
day.
● Your total treatment time for the day divided by your total time spent at work for the day.
● Productivity = billable hours/ total hours worked
4. Review the slide on ICD10 codes.
● 2 categories
○ Medical Dx - primary dx of patient
○ Treatment Dx - why you need to be treating, medical necessity