7: Occupational therapy intervention

CHAPTER 7
Occupational therapy intervention


7.1 Introduction


Occupational therapists offer a range of interventions and management strategies to support people living with long-term neurological conditions to maximise their existing skills and resources and to support successful engagement in meaningful occupations. This can include a range of practical, occupation-focussed interventions and behavioural approaches aimed at changing maladaptive responses into positive approaches which support the person living with a long-term neurological condition to maximise opportunities for engagement and wider participation. This chapter explores a range of rehabilitative interventions to support the occupational therapist to work collaboratively with the person living with a long-term neurological condition to achieve their occupational goals.


7.1.1 Rehabilitation interventions


Rehabilitation is defined as ‘a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments’ (World Health Organisation, 2011). Rehabilitation aims ‘through peer support, to enable persons with disabilities to attain and maintain their maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life’ (von Groote et al., 2011).


Rehabilitation measures are aimed at achieving the following broad outcomes (World Health Organisation, 2012):



  • Prevention of the loss of function
  • Slowing the rate of loss of function
  • Improvement or restoration of function
  • Compensation for lost function
  • Maintenance of current function.

7.2 Activities of daily living


The term ‘activities of daily living’ is used to describe fundamental aspects of self-care which are performed as part of our everyday routines. Symptoms such as pain, fatigue, weakness and balance can impact on the successful completion of activities including eating, dressing, bathing, toileting and grooming. The occupational therapist should consider a range of strategies which are relevant and appropriate to each individual person. Some general principles which can be applied to support activities of daily living include the following:


7.2.1 Dressing



  • Lay out clothes before starting to get dressed and place them on the bed or a chair so that they are within easy reach avoiding unnecessary bending or stretching.
  • Sit down to get dressed if balance is impaired.
  • Apply all lower garments first before standing to adjust clothing. This minimises the need for repeated standing and conserves energy.
  • Avoid tight-fitting garments if sitting for prolonged periods in a wheelchair.
  • Use garments with elasticated waist for easier access for toileting.
  • Avoid small fastenings, including buttons and zip fasteners.
  • Avoid shoes with laces, choose slip-on shoes or Velcro fastenings.
  • Cotton garments may be more comfortable than man-made fibres such as nylon or polyester.

7.2.2 Eating and drinking



  • Ensure a good upright position can be maintained throughout mealtimes.
  • Smaller portions may be easier to manage and prevents food from getting cold.
  • Plate warming devices may help keep the food more appetising.
  • If the person needs assistance to cut up food, this should be done discretely in advance of serving the meal.
  • Non-slip mats, adapted cutlery and plate guards may help to manoeuvre the food onto a fork or spoon.
  • Consider using a spoon instead of a fork.
  • Avoid filling glasses and cups to prevent spilling if tremor is apparent.
  • Two-handled mugs or heavier mugs may help reduce tremor.
  • Electronic eating devices or mobile arm supports may assist with eating.
  • Consider using thickeners in liquids if choking becomes apparent and refer to speech and language therapy for further advice.

7.2.3 Toileting



  • Consider using fixed grab rails by the toilet.
  • Avoid using free-standing toilet frames for people with Parkinson’s or Huntington’s (Aragon and Kings, 2010; Cook et al., unpublished) as the movement within them can interfere with safe transfers.
  • Choreic movements or excessive force when sitting can lead to increased pressure on toilet seats which may break more frequently (Cook et al., unpublished).
  • Use of washing and drying toilet facilities should be considered to promote personal hygiene.
  • Garments which can be easily laundered should be considered when bladder and bowel problems exist.
  • When bladder problems exist darker coloured clothing may be more discrete in the event of an ‘accident’.

7.2.4 Bed mobility



  • Teach methods for turning and rolling in bed.
  • Consider using satin night-wear or bedclothes to aid movement in bed (Aragon and Kings, 2010).
  • Use of additional pillows or foam wedges help maintain posture and prevent sliding.
  • Encourage the person to get into bed by sitting on the edge of the bed near to the pillows and lifting legs into bed before lying down (Aragon and Kings, 2010).

7.2.5 Grooming



  • Use of an electric shaver or beard trimmer is safer than a wet shave (Cook et al., unpublished).
  • Shorter hairstyles are easier to manage, but for those people who wish to keep longer hair a ‘tangle teaser’ brush or spray-in conditioner helps to keep hair manageable (Cook et al., unpublished).

7.3 Fatigue management


Fatigue management incorporates a self-management approach to supporting the person living with a long-term neurological condition to increase their understanding of the factors contributing to or exacerbating fatigue and through education and adaptation learning to optimise their function (Harrison, 2007). Fatigue management can be applied at an individual level or can be carried out as a group activity, for example the FACETS (Fatigue: Applying Cognitive behavioural and Energy effectiveness Techniques to lifeStyle) programme (Thomas et al., 2010).


The key principles of fatigue management include the following:



  • Education to develop an understanding of energy conservation strategies
  • Generation of practical solutions including access to resources and equipment
  • Development of strategies which challenge underlying health beliefs
  • Increased activity and participation through collaborative goal setting.

7.3.1 Practical strategies for energy conservation


The following practical strategies for energy conservation have been adapted from Harrison (2007).


Take frequent rests



  • Build in time for rest within and between everyday activities.
  • Taking regular, short rests instead of one long rest, that is sitting down for 5 minutes while vacuuming a room instead of waiting until the room is completely vacuumed and then taking a 30-minute rest.

Prioritise activities



  • List all the jobs which need to be done across the day/week.
  • Delegate jobs which can be done by somebody else.
  • Ask for help! Access help from others, including external agencies.
  • Reduce or cut out jobs which may not be necessary, for example folding washing may prevent the need for ironing or avoid ironing items such as socks or towels.
  • Consider how certain tasks are completed, for example washing small amounts everyday instead of a large wash once a week to spread out the amount of work.

Plan ahead



  • Complete the most important tasks first to prevent running out of energy.
  • Use schedules or plans of activities on a daily or weekly basis.
  • Spread heavy and light tasks across the day.
  • Don’t be too ambitious! Set realistic targets.
  • Try to avoid tasks which cannot be stopped should you feel tired.

Organise tools, materials and work area



  • Organise work areas to reduce effort and unnecessary movements including bending.
  • Ensure lighting is good to prevent eye strain.
  • Think about the temperature of the room and try to avoid it becoming too hot.
  • Organise areas to make sure that relevant items are close at hand, for example arrange cupboards to place most frequently used items at the front.
  • Try to avoid clutter.

Adopt a good posture



  • Try to reduce stress on the body, moving efficiently, avoiding twisting and bending.
  • Maintain symmetry and an upright posture during tasks.
  • Rest between repetitive tasks.


Lead a healthy lifestyle



  • Choose activities that you enjoy.
  • Use the correct equipment.
  • Build up slowly to new activities.
  • Plan exercise as part of daily/weekly routines.
  • Eat a well-balanced diet.
  • Avoid heavy meals.
  • Remember that excess weight, alcohol and smoking can all have a negative effect on fatigue.

7.4 Cognitive rehabilitation


Cognitive rehabilitation can be described as any intervention strategy or technique which enables people living with a long-term neurological condition and their families or carers to live with, manage, by-pass, reduce or come to terms with cognitive deficits (Wilson, 1987). Cognitive rehabilitation utilises therapeutic activities in a systematic way to promote functional changes within the person’s everyday life and also have a key role to play in occupational therapy practice (Worthington, 2007, p. 266).


Occupational therapy interventions aimed at cognitive rehabilitation tend to fall within the following two main categories of approach:



Due to the progressive nature of their diseases, people living with a long-term neurological condition are often considered to be poor candidates for cognitive rehabilitation, but this should be considered within the selection of interventions to best meet the their needs (Brooks and Matson, 1982).


7.4.1 General principles of cognitive rehabilitation



  • Interventions must be tailored to suit the individual.
  • Interventions are most effective when developed collaboratively between the person living with a long-term neurological condition, their family and the occupational therapist.
  • Interventions should be focussed on mutually set and functionally relevant goals.
  • Evaluation of the efficacy and outcome should incorporate and capture changes in functional abilities.
  • The most successful cognitive interventions involve multiple approaches.
  • Interventions should recognise the person’s awareness of their situation and their ability to self-regulate behaviour and emotion.
  • Interventions should address the person’s emotional response to cognitive challenges and their general coping style, for example getting angry or frustrated.
  • Interventions should be self-evaluative, that is the person living with a long-term neurological condition needs to be able to determine if change or improvement has occurred.

7.4.2 General principles in the management of memory disorders


Encoding (the registration of information)



  • Simplify the information.
  • Reduce the amount of information.
  • Make sure information is understood.
  • Link/associate information, for example remember a shopping list by rooms in the house.
  • Little and often rule.
  • Encourage organisation.
  • Process information at a deeper level, for example using emotional or visual connection with the information.

Storing



  • Test/rehearse/practice.
  • Use expanding rehearsal, that is begin with a small amount of information and learn it before adding another section.

Retrieval



  • Present information in several different contexts such as questioning in a different way: Do you go out much? When do you go swimming? Is it Monday or Tuesday when you go swimming?
  • First letter prompts, for example his name starts with ‘J’.
  • Alphabetical searching, for example when trying to remember items on a shopping list: apples, bread, cat food.
  • Mental retracing, that is imagining being in the room or in the situation where the event occurred, for example mentally walking through each room in your house as you stand in the supermarket to remember what you need to buy. You then recall that as you were showering in the morning you ran out of shower gel.

7.4.3 Commonly used intervention strategies


Environmental interventions



  • Labelling cupboard contents.
  • Message centre on fridge door.
  • Use of cues, for example note on door to remember keys.
  • Use of checklists, for example dressing sequence.
  • Organisation of physical space, for example keep free from clutter and distraction.

Compensatory devices and strategies



  • Calendars.
  • Alarm clocks.
  • Mobile phones.
  • Personal computers and tablets.
  • Paging systems.

Specialised instruction techniques



  • Mnemonics, for example Every Good Boy Deserves Food to learn musical notes.
  • PQRST (Preview-Question-Read-State-Test) when reading, for example newspaper articles.
  • Errorless learning.
  • Direct instruction techniques.
  • Procedural learning.

7.4.4 Generalisation


Generalisation or transfer of training refers to the application of a skill learned in one particular situation to a different but similar situation. Strategies which are used within one context may not apply within another, for example PQRST might help with reading short articles in the newspaper but not when reading longer chapters of a book. Similarly the person living with a long-term neurological condition may find that some strategies work well for a particular problem but not for others, for example mental retracing to remember a shopping list might not help with remembering names. Failure to generalise, however, does not mean that the intervention is not effective but that further discussion may be required between the occupational therapist and the person living with a long-term neurological condition to find the most appropriate solution.


7.5 Anxiety management


Anxiety is a feeling that is common to us all at some stage within our daily lives and is generally perceived as a natural reaction to certain situations and circumstances (SANE, 2015). For most people, this tends to pass relatively quickly without any interventions. However for some people living with a long-term neurological condition this can be become quite disabling and can interfere with daily life.


Diagnosis with a long-term neurological condition can lead to a fear or apprehension of what lies ahead or what the future might hold. Anxiety often goes hand-in hand with depression and can become a major barrier for some people living with a long-term neurological condition impacting on their ability to engage in their chosen occupations, their relationships and their interactions with their environment. Feelings of inadequacy and an inability to cope with the demands placed upon them can lead to challenges for the person living with a long-term neurological condition, their family and friends.


7.5.1 Symptoms of anxiety


Psychological effects of anxiety may include the following (SANE, 2015):



  • An overwhelming sense of fearful anticipation
  • Inability to concentrate
  • Constant worrying
  • Heightened alertness and a tendency to ‘catastrophise’
  • Sleep disturbance.

Physical effects may include the following:



  • Tightness in the chest, chest pains or a ‘pounding’ heart
  • Nausea
  • Rapid shallow breathing or butterfly feelings in the stomach
  • Loss of appetite
  • Headaches
  • Dizziness or feeling faint
  • Muscle tension
  • Sweating
  • Frequent urination
  • Panic attacks.

7.5.2 Strategies for managing anxiety


Understanding anxiety


People understand anxiety in different ways, and this can impact on how they then choose to manage it. For some people living with a long-term neurological condition, anxiety serves as a protective function as they believe that by anticipating certain dangers they can recognise and avoid them or that they will be better prepared to cope with them. This can however lead to unnecessary worrying and the person living with a long-term neurological condition may begin to worry about the amount of time they spend worrying, becoming increasingly focussed on the symptoms of anxiety, which in turns adds to their worry. This focus on potential danger may also lead to the person living with a long-term neurological condition avoiding situations or disengagement in certain occupations.


Time use may also contribute to levels of anxiety as lack of time for relaxation can contribute to higher levels of anxiety. Conversely having too much time to dwell on potential dangers may mean that the person living with a long-term neurological condition has more opportunities to engage in worry and feel anxious (adapted from Moodjuice, 2015).


Challenging patterns of unhelpful thinking


It is common when living with a long-term neurological condition to spend a lot of time thinking about the future and predicting what could go wrong, for example ‘I’ll be using a wheelchair within 2 years’. For others they may make assumptions about other people’s beliefs without any real evidence to support them, for example ‘they think I’m drunk at 5 o’clock in the morning’. One of the main factors contributing to heightened anxiety for people living with a long-term neurological condition however is catastrophising or blowing things out of proportion, that is they assume that something that has happened is far worse than it really is, for example ‘I won’t get another occupational therapy appointment because I forgot about the last one’, or they may think that something terrible is going to happen in the future, when in reality, there is very little evidence to support it, for example ‘My children will be taken from me if I’m not able to look after them properly’.


People living with a long-term neurological condition may focus on the negatives or imagine how things ought to be, applying extra pressure on them to achieve perfection. Loss of confidence also contributes to anxiety and previous experiences or isolated incidents can lead to the person living with a long-term neurological condition worrying that the same thing will happen again, for example ‘I went shopping with my friends and couldn’t find a toilet. I spent all the time worrying in case I had an accident, so now I don’t go shopping’. Attachment of negative labels by the person living with a long-term neurological condition can influence how they see themselves and can further heighten anxiety levels, for example ‘I’m stupid’, ‘I’m useless’ or ‘I’m a burden to my family’ (adapted from Moodjuice, 2015).


The occupational therapist can help the person living with a long-term neurological condition to recognise and challenge unhelpful thoughts. This is done by asking the following series of questions (adapted from Moodjuice, 2015):



  1. Is there any evidence that contradicts this thought?

    • I’ve always been the one to support my family
    • I’m always there to look after my children

  2. Can you identify any of the patterns of unhelpful thinking described earlier?

    • I see parents much worse than me and their children haven’t been taken from them.

  3. What would you say to a friend who had this thought in a similar situation?

    • I’d say, don’t be ridiculous you are a great mother. You are always there for your children. As long as you look after your own health you should be fine. Besides, you can only do your best.

  4. What are the costs and benefits of thinking in this way?

    • Costs: it’s making me feel sick with worry
    • Benefits: I can’t really think of any

  5. How will you feel about this in 6 months?

    • I will still probably be worrying about how good a mother I am because that is the type of person I am. I never like to give myself credit for doing a good job.

  6. Is there another way of looking at this situation?

    • I make sure that the children don’t see me at my worst. I often rest when they are in school so that I have the energy to do things with them when they come home. Most parents get tired at some point.

  7. Try to come up with a more balanced or rational view.

    • I’ve worried about this since the children were born and they seem to be doing okay, so far. I’m sure every parent worries about how they bring up their children but I just worry more because of my condition, which probably has nothing to do with how good a parent I am.

Problem solving


People living with a long-term neurological condition might find it more difficult to cope if they feel they have lots of problems that they can’t seem to get on top of. This ultimately leads to worrying or ruminating over the problems without finding a way to resolve them, making the person living with a long-term neurological condition feel more upset or even interfere with their sleep. Use of a problem-solving approach can support the person living with a long-term neurological problem to clearly articulate and frame the problem, identify priorities and generate potential solutions to overcome the problem (adapted from Moodjuice, 2015). An example of applying a problem-solving approach might include (adapted from Moodjuice, 2015):



  1. What is the problem? Try to be as specific as possible.

    • e.g. I won’t be able to go shopping if I no longer have a driving license.

  2. How have you solved similar problems in the past?

    • e.g. I used to get a lift from my friend/I used on-line shopping/I used public transport/my husband did the shopping on his way home from work

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Feb 18, 2017 | Posted by in NEUROLOGY | Comments Off on 7: Occupational therapy intervention

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