Hand and Upper Extremity Care: Specialization-Get the Secret Out!

By: Mojca “MO” Herman, MA, OTR/L, CHT

Photo credit: Pragmagraphr / Foter / CC BY-NC-ND

Photo credit: Pragmagraphr / Foter / CC BY-NC-ND

The epidemiology of upper extremity injuries is not well studied; furthermore it appears the rate of incidence is not predicted to slow down any time soon. A 2012 retrospective national study estimated that 3,468,996 upper extremity trauma cases were treated in the emergency department (Oootes, Lambert, & Ring, 2012). The impact that these injuries place on an individual can be life altering; exacerbated by family and work obligations, insurance benefits, as well as emotional, physical, mental and financial strains.

In light of increasing costs and decreasing reimbursement, it is acutely important that individuals with an upper extremity injury pursue the most appropriate and specialized providers in a timely manner. The first step to specialization involves finding an orthopedic doctor that exclusively treats upper extremity injuries; a hand surgeon. The second step entails locating a hand therapist who specializes in upper extremity rehabilitation; a Certified Hand Therapist (CHT). Hand surgeons reliably refer patients to CHTs and the specialty of hand therapy.

Case Study

The following case study outlines a simple injury that resulted in an unnecessarily time consuming, frustrating and costly recovery.

A 37-year-old right hand dominant female sustained a left index finger injury on 7/8/14 while on vacation with her family. She is a married mother of 2 children, employed full time as an Administrative Assistant, and is extremely active with various outdoor hobbies.

The mechanism of injury was a sudden stop on a ski boat that caused the patient to slice the web space of her index finger on a hinge. She went to the ER the same day, had x-rays taken that were negative, received 7 stitches, and was instructed to keep her finger dry for 14 days. She was not given a referral for any specialized follow-up; furthermore she was not advised to perform any exercises. She was only advised to return in 2 weeks for stitch removal.

Since her injury occurred while on vacation, she had her stitches removed at home, but did not receive further medical intervention.

One month after the injury, her finger was getting worse; it was stiffening into a bent position resulting in less ability to straighten. Her chronically bent finger was impacting her functional use during daily life. She opted to consult with her general orthopedic doctor, who took further x-rays that were negative, and referred her to general physical therapy.

She attended general physical therapy for approximately one month, and overall did not make any sustainable gains.

She returned to her orthopedic doctor who ordered an MRI, and the results were negative. He referred her for a second opinion.

The second opinion also took x-rays and sent her to therapy but did not give her a direct referral since she lived far away.

Approximately 2 months had passed since her initial date of injury, and her finger was progressively losing extension and function. She referred to it as a “hook finger”. Needless to say she was frustrated.

She decided it was time to take matters in her own hands, and advocate for herself since she felt the medical system was failing her finger. She conducted her own research and located a reputable hand surgeon in her local area.

She consulted with the hand surgeon, her third doctor, approximately 2.5 months after her injury. He reviewed her MRI, diagnosed her with proximal interphanlangeal (PIP) joint flexion contracture, and referred her to hand therapy. He did inform her that with the time delay, she might have to face surgery if the therapy was not successful.

Approximately 3 months after her initial injury, on 10/1/2014, she consulted a Certified Hand Therapist at. She underwent a detailed and comprehensive evaluation that included assessment of her edema, range of motion, strength, pain, sensation, and functional impairment. Her main subjective complaints included pain, lack of motion and dropping items due to motion loss and inability to grip. Her immediate short-term goals were to make a full fist and fully open her finger so that she could resume her hobbies and be more productive at work.

She openly expressed pessimism in any hopes of more recovery given her lengthy and time-consuming visits to endless doctors with no improvements. She was also worried about the costs she was incurring.

Given that she wanted to avoid surgery, she was willing to give therapy one more try since she was now FINALLY consulting with a specialist in upper extremity rehabilitation.

Treatment Intervention:

Based on the detailed evaluation, she was given a custom tailored home exercise program for range of motion, edema management and splinting (Wollstein, R., Rodgers, J., Ogden, T., Loeffler, J., & Pearlman, J., 2012).

For edema management, she was educated on: retrograde massage, compression wrap for the finger, and ice.

The importance of general movement and range of motion was also stressed as she was compensating by using the rest of her digits, avoiding the index finger all together. She was initially directed to “buddy tape” to her middle finger to cue her to integrate it back into her daily living until it became more automatic.

Regarding splinting, a finger based serial static custom PIP (DIP was included) extension orthosis was fabricated (Puri, et al., 2013). It was created at the end of the therapy session when she was in as much PIP extension as possible. She was instructed to wear it at night and intermittently during the day (Glasgow, Wilton, & Tooth, 2003). Over the duration of her sessions, it was serially molded in greater PIP extension as the tissue allowed for it.

Had she not been so compliant with her daily home exercise program, a PIP/DIP flexion strap for daytime would have been indicated – to regain terminal flexion; but her self-directed exercises ultimately led to improved end flexion.

Outcomes:

Outcomes were measured using objective tools including: grip dynamometer; pinch gauge; manual muscle testing (MMT); ROM with goniometer; Semmes-Weinstein Monofilaments for sensation; measuring tape to track improvement in edema; Visual Analog Scale for pain; Upper Limb Functional Index (ULFI) (Gabel, Michener, Burkett, and Neller, 2006) in addition to the Functional Independence Measure (FIM) to capture global occupational engagement.

Despite her uphill battle, she was motivated and compliant. She met her short-term goals in 3 sessions and was astonished at the rate of recovery in the hands of an expert. Simple phrases she expressed in her short time of specialized care:

“If I had only known you existed, I would have come directly to you.”

“ I would have saved so much time and money.”

“You need to get the word out. I will tell my orthopedist about you.”

“I accomplished more in three sessions than I did in the past 3 months.”

“Amazing!”

In light of changing healthcare, there is a greater need for educating the community regarding the existence of hand and upper extremity specialization, as well as for advocacy of the specialized care. Thanks to direct access to Internet search engines, websites, and patient reviews, informed research is readily available to the provider and consumer. In order to ensure efficiency, maximize recovery, and reduce costs, individuals with arm injuries need to advocate to be seen promptly by the hand and upper extremity experts. Help us get the secret out.

Photo credit: anne-ostsee / Foter / CC BY-NC-SA

Photo credit: anne-ostsee / Foter / CC BY-NC-SA

Information about CHT

What is a Certified Hand Therapist (CHT)?

A Certified Hand Therapist (CHT) is a board certified occupational or physical therapist that has a minimum of five years of clinical experience, a minimum of 4,000 hours in the direct practice of hand therapy, and has successfully passed a comprehensive advanced upper extremity exam. A CHT is the ultimate specialized credential a hand therapist can achieve.

What diagnoses does a hand therapist treat?

Surgical and non surgical conditions can include but are not limited to: finger/thumb sprains/strains, ligament and tendon injuries, dislocations, wrist fractures, carpal tunnel syndrome, trigger fingers/thumb, arthritis, tennis elbow, golfers elbow, repetitive strain injuries, nerve injuries/compressions, DeQuervain’s, thoracic outlet syndrome, frozen shoulder, rotator cuff injuries, general upper extremity fractures, amputations, burns, and tumors/cysts.

Hand therapists are trained in the use of various modalities to help reduce pain and swelling, i.e., ultrasound, heat, ice, paraffin, kinesiotape, iontophoresis, and other modalities that can assist with muscle re-education, i.e. electrical stimulation. Hand therapists are also advanced trained in ergonomic education, work hardening, activity modification as well as energy conservation and joint protection.

Skilled hands-on techniques include: soft tissue manipulation for swelling, scar tissue, and muscle tightness; manual stretching/mobilization of tight joints and muscles, as well as wound/scar management including desensitization and sensory re-education.

Lastly, hand therapists are remarkably proficient in assessing the need for custom splints/orthoses for various purposes. These could range from initial acute protection, to mobilizing stiff joints, as well as providing a safeguard when individuals resume life, work, sports and hobbies. Hand therapists are highly skilled at fabricating, adjusting, modifying and progressing the splints as the healing tissues improve. Customized splinting is a paramount adjunct to the hands-on therapy provided by hand therapists.

How do I find a Certified Hand Therapist in my area?

There are two entities that have searchable databases for locating a certified hand therapist. First, The Hand Therapy Certification Commission (HTCC) represents 6,005 Certified Hand Therapists worldwide. (CHT’s by profession: 85% Occupational Therapists, 14% Physical Therapists, and 1% is represented by both professions.) Second, most CHT’s belong to the American Society of Hand Therapists (ASHT), a professional organization comprising of over 3200 licensed occupational and physical therapists worldwide specializing in the rehabilitation of the upper extremity.

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About the Author

Mojca, “MO” Herman, MA, OTR/L, CHT, a former Olympian, has over 20 years of clinical experience and is currently in her 12th year of private practice in Torrance, California at the Advanced Therapy Center, an outpatient hand therapy clinic that specializes in hand and upper extremity care. Mo is involved in various hand therapy-related activities. She serves as a member of the ASHT Board of Directors and is an annual guest lecturer at the USC Graduate Occupational Therapy Program and at the UCLA Hand Surgeon Conference. She has co-authored several chapters on a variety of hand therapy topics for books and journals and has presented various courses at local and national level conferences. She is the recipient of the ASHT 2014 President’s Award in recognition of society contributions.

 

References 

Gabel, C.P., Michener, L.A., Burkett, B., & Neller, A. (2006). The Upper Limb Functional Index: Development and determination of reliability, validity, and responsiveness. Journal of Hand Therapy, 19(3): 328-349.

Glasgow, C., Wilton, J., & Tooth, L. (2003). Optimal daily total end range for contracture: Resolution in hand splinting. Journal of Hand Therapy, 16(3), 207-218.

Ootes, D., Lambers, K.T., & Ring, D.C. (2012). The epidemiology of upper extremity injuries presenting to the emergency department in the United States.   Hand (N Y). 7(1): 18–22.

Puri, V., Khare, N., Venkateshwaran, N., Bharadwaj, S., Choudhary, S., Deshpande, O., & Borkar, R. (2013). Serial splintage: Preoperative treatment of upper limb contracture. Burns, 39(6): 1096-1100.

Wollstein, R., Rodgers, J., Ogden, T., Loeffler, J., & Pearlman, J. (2012). A novel splint for proximal interphalangeal joint contractures: A case report. Archives of Physical Medicine and Rehabilitation, 93(10): 1856-1859.

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Pediatric Feeding: Skills, Competency & Function

By: Lisa A. Olsen, OTD, OTR/L

Photo credit: sunsurfr / iwoman / CC BY-NC-SA

Photo credit: sunsurfr / iwoman / CC BY-NC-SA

Introduction:

The purpose of this paper is to visually demonstrate through the use of a concept map, the multidimensional and multifaceted aspects of feeding and eating, with pediatric patients and identify the need for a collaborative multidisciplinary team approach to this seemingly ordinary activity of daily living (ADL) (Miller, et. al., 2001). The American Occupational Therapy Association (AOTA) Practice Framework, & position paper for Specialized Knowledge & Skills for Feeding, provides foundational guidelines of how occupational therapy (OT) should be involved in this daily occupation (AOTA, 2008, 2007).

A Concept Map is utilized in order to effectively discuss and visually describe the topic of Pediatric Feeding involving skills, competency and function. The topic and format is intended to inform occupational therapy practitioners, occupational therapy students and non- OT healthcare professionals. The concept map supports the effort to coordinate evaluation and treatment as a team and as an individual OT clinician to facilitate pediatric feeding success and to identify the interrelationship between the medical, physical, sensory, behavioral, social, emotional and environmental aspects of feeding.

Objectives:

Assist the practitioner to identify the multifaceted and multidimensional aspects of feeding and eating; inform identification of interventions used to facilitate successful pediatric feeding by occupational therapists and other healthcare professionals and, educate OTRs, OT students and non-OT healthcare professionals regarding the multidimensional aspects of pediatric feeding and the role of OT in feeding.

Methods:

The concept map is broken into sections to demonstrate the interrelationships between the physical, medical, sensory, behavioral, psychosocial, emotional, spiritual and environmental aspects of feeding and eating. It presents a holistic view of facilitating successful function and engaging in purposeful activity (AOTA, 2008). The map itself utilizes color clusters to show different categories and relationships with the concepts and elements of feeding. Connecting words help tell the story of how feeding is multidimensional, multifaceted and multidisciplinary to include the role of OT as well as nursing, physicians and other health care personnel (AOTA, 2008).

Click to Enlarge

Click to Enlarge

The concept map indicates the process of evaluation and assessment as the first step in addressing pediatric feeding. Typical assessment includes: gathering of patient medical history, medical testing, physical exam and instrumental assessments for the swallow such as the modified barium swallow study (MBSS) (Wilcox, Liss, & Siegel, 1996); flexible endoscopic evaluation of swallowing (FEES) (Hoppers & Holm, 1999); Cervical Auscultation-(stethoscope listen to swallow); upper GI; and review of lab tests, general x-ray, CT, MRI and ultrasound. Further, the feeding specialist or OT practitioner will then perform a clinical assessment reviewing the status of the anatomy, head and neck, swallowing mechanisms, function/dysfunction of the cranial nerves, oral motor skills and performance and actual feeding trials when possible (Howe & Wang, 2013).

Testing methods can include use of the Morris & Klein pre-feeding scales (2000) to identify age levels related to skills and the use of the Schedule for Oral Motor Assessment (Ko, Kang, Ko, Ki, Chang, & Kwon, 2011). Sensory function of global sensory processing and sensory responses of the oral motor area are evaluated with both nutritive and non-nutritive means. Assessment as well as intervention also includes attention to positioning and the environment. Additional components of consideration include: position used when feeding and not feeding; child’s tolerance of position changes; caregiver management of position; us of or indication for seating/equipment; alignment of the trunk, head, neck and jaw, and the child’s responses to noise, light and distractions (Morris & Klein, 2000).

The psychosocial aspect of feeding is evaluated as eating takes place in community; at home or in public; for celebration, or life sustaining purposes. Occupational therapy looks at the holistic needs and influences of this activity of daily living and how important it is to the individual socially, emotionally, spiritually and functionally (AOTA, 2008, 2007). Family time, one on one time with the care giver, gatherings with friends or colleagues are all part of the psychosocial aspects of the feeding and eating occupation.

Sensory concerns such as taste, touch and smell of the food as well as the utensils, equipment, sounds and distractions and their influence on feeding are also identified.

The map then indicates how issues of sensation and sensory processing influence feeding and can have an impact on behavior demonstrating a relationship between behavior and sensory difficulties (Davis et. al., 2013). Behavior can be influenced by overall sensory processing expressed as fight or flight, poor self-esteem; irritability; produce battles, struggles and stress with care givers, and can be influenced by peers and social pressure (Clawson, Kuchinski, Bach, 2007; Davis et. al., 2013).

Finally, the concept map identifies the areas of direct intervention by the OT related to oral motor activities and eating activities (Sheppard, 2008).  The map identifies the different stimulation activities to the oral motor structures and the activities related to manipulation of foods, utensils, equipment, positioning, the environment, and experiences of emotion and performance (Clark, Lazarus, Arvedson, Schooling, & Frymark, 2009).

In conclusion, the concept map provides a visual explanation of how OT works with pediatric patients to facilitate successful feeding and eating with multidimensional and multidisciplinary considerations (Arvedson, Clark, Lazarus, Schooling & Frymark, 2010). Occupational Therapy takes a holistic, multifaceted, multidimensional and multidisciplinary approach towards success with pediatric feeding (AOTA, 2008). This concept map allows the OT to inform fellow practitioners, students and other healthcare professionals in how the process of pediatric feeding requires a team approach (Miller, et. al., 2001).

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To read more on dysphagia, visit our sister site Dysphagia Cafe

 

About the Author

Lisa Ann Olsen, OTD, OTR/L is a pediatric occupational therapist practicing in Orange County, California.  She received her B.S. from the University of Southern California and her doctorate from Creighton University in Omaha, Nebraska. Dr. Olsen presented her conceptual model for pediatric feeding skills at the 2014 OT Association of California annual conference. She has her CA Advanced Practice license for Swallowing Assessment, Evaluation, and Intervention.

 

References

  1. American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62(6), 625-683.
  1. American Occupational Therapy Association. (2007). Specialized knowledge and skills in feeding, eating and swallowing for occupational therapy practice. American Journal of Occupational Therapy, 61, 1-29.
  2. Arvedson, J., Clark, H., Lazarus, C., Schooling, & Frymark, T. (2010). Evidence-based systematic review: effects of oral motor interventions on feeding and swallowing in preterm infants. American Journal of Speech-Language Pathology, 19, 321-340.
  1. Clark, H., Lazarus, C., Arvedson, J., Schooling, T., & Frymark, T. (2009). Evidence-based systematic review: Effects of neuromuscular electrical stimulation on swallowing and neural activation. American Journal of Speech-Language Pathology / American Speech-Language-Hearing Association, 18(4), 361-375.
  1. Clawson, E., Kuchinski, K., Bach, R. (2007). Use of behavioral interventions and parent education to address feeding difficulties in young children with spastic diplegic cerebral palsy. Neurorehabilitation, 22(5), 397-406.
  1. Davis, A., Bruce, A., Khasawneh, R., Schulz, T., Fox, C., & Dunn, W. (2013). Sensory processing issues in young children presenting to an outpatient feeding clinic. Journal of Pediatric Gastroenterology and Nutrition, 56(2), 156-160.
  1. Hoppers, P., & Holm, S. (1999). The role of Fiberoptic endoscopy in dysphagia rehabilitation. Journal of Head Trauma Rehabilitation, 14(5), 475-485.
  1. Howe, T., & Wang, T. (2013). Systematic review of interventions used in or relevant to occupational therapy for children with feeding difficulties ages birth -5 years. American Journal of Occupational Therapy, 67(4), 405-412.
  1. Ko, M., Kang, M., Ko, K., Ki, Y., Chang, H. & kwon, J. (2011). Clinical usefulness of schedule for oral-motor assessment (SOMA) in children with dysphagia. Annals of Rehabilitation Medicine, 35, 477-484.
  1. Miller, C. K., Burklow, K. A., Santoro, K., Kirby, E., Mason, D., & Rudolph, C. D. (2001). An interdisciplinary team approach to the management of pediatric feeding and swallowing disorders. Children’s Health Care, 30(3), 201-218.
  1. Morris, S. & Klein, M. (2000). Pre-feeding skills: a comprehensive resource for feeding development: Second edition. Tucson, AZ: Therapy skill builders.
  1. Sheppard, J. (2008). Using motor learning approaches for treating swallowing and feeding disorders: a review. Language, Speech and Hearing Services in Schools, 39, 227-236.
  1. Wilcox, F., Liss, J. M., & Siegel, G. M. (1996). Interjudge agreement in videofluoroscopic studies of swallowing. Journal of Speech and Hearing Research, 39(1), 144-152.

Review of the Evidence Regarding Safe Activity and Mobilization with Acute Venous Thromboembolism

By: Michelle de la Garza OTD, OTR/L

Photo credit: Pulmonary Pathology / Foter / CC BY-SA

Photo credit: Pulmonary Pathology / Foter / CC BY-SA

Every year in the United States it is estimated that up to 2 out of every 1000 people are diagnosed with a deep vein thrombosis (DVT) or pulmonary embolism (PE). Between 10 to 30 percent of those will be cases that end in death within 30 days of diagnosis. Additionally, sudden death occurs in nearly 25 percent of all diagnosed PEs (Centers for Disease Control and Prevention, 2014). The risk factors for developing a DVT or PE include high blood pressure, history of stroke, chronic heart disease, and chronic obesity (National Institutes of Health, 2011). With these comorbidities on the rise (National Institutes of Health, 2011), it is likely that the number of patients with DVT and PE will also rise. As health care systems are pressured to provide care with shorter lengths of stay and better clinical outcomes, it is important for occupational therapists to utilize best practice in treating this patient population.

Clinical Scenario

A physician writes an order for OT Eval and Treat on a patient newly diagnosed with a PE. Because the health care center is striving to keep length of stays short and social work is pressing you for discharge recommendations, you want to initiate OT services as soon as possible to assess the patient’s independence and safety with ADLs. However, you don’t want to do so if the patient is medically unstable, putting the patient at greater risk for cardiac arrest and other complications. You need a quick tool to verify that the patient is reasonably stable and appropriate to begin OT treatment.

Pulmonary Embolism Severity Index

 

The Pulmonary Embolism Severity Index (PESI) was created to categorize the severity and risk of mortality for patients with PEs. The developers of this tool identified 11 independent indicators that have been clinically associated with mortality in patients diagnosed with acute PE (Aujesky et al., 2005). Patients who are hemodynamically stable will score in the Low Risk of mortality range – Classes I and II – with scores of less than or equal to 65 and 66-85, respectively. Hemodynamically unstable patents are in a High Risk of mortality range – Class V – with a score greater than 125. Patients with scores of 86-105 and 106-125 – Classes III and IV, respectively – are considered Intermediate-High Risk of mortality (Aujesky et al., 2005).

Information regarding parameters for recommended activity or recommended bed rest for a PESI score above 125 was unable to be found in Level I or II evidence pools. Clinical judgment and/or physician specific protocols are likely used in such cases. When considering the criteria for scoring the PESI, the possibility that a patient with a high score would also have comorbidities that further complicate activity is quite likely.  So regardless of pulmonary status, the treating clinician is surely assessing other medical issues before proceeding with treatment. Overall, studies using the PESI scores have indicated that patients with non-High Risk scores (<125) have safely been treated without bedrest or activity restriction and discharged within 24 hours of diagnosis. These patients do not show a statistically significant increase in mortality or complications as compared to those patients treated with longer inpatient stays, including days of restricted activity (Yoo, Queluz, & El Dib, 2014; Othieno, Abu Affan, & Okpo, 2007). This body of research uses subcutaneous Heparin (1mg BID) to treat the PE, which is considered best practice due to its effectiveness, fast results, and easy administration (Yoo et al., 2014; Othieno et al., 2007; Aujuesky et al., 2014). These findings indicate that patients with acute PEs and appropriate anticoagulation treatment who also have non-High Risk PESI scores can be considered for safe early mobilization and to resume ADL performance. This supports related research regarding DVT best practices including: increased physical activity reduces recurrence of DVT, reduces extension of DVT, and can reduce pain symptoms of DVT in conjunction with anticoagulation treatment (Kahn, Shrier, & Kearon, 2008; Blattler & Partsch, 2003).

An alternate treatment for PE is use of a thrombolytic agent. This is contraindicated in PESI class I and II patients due to an increased incidence of major bleeding events and intracranial hemorrhage. Anticoagulation therapy is preferred for low and intermediate-high risk PEs (Riera-Mestre, Becattini, Giustozzi, & Agnelli, 2014).

Special Considerations

As with any protocol or assessment tool, clinical reasoning and clinical observations must be considered before and during occupational therapy treatment. Additional considerations include comorbidities such as cancer and history of cancer, pregnancy, trauma, and renal insufficiency (Aujesky et al., 2005; Yoo et al., 2014; Othierno et al., 2007). Patients with these comorbidities were widely excluded in the research. Additionally, therapists should identify the method of anticoagulation being used with each patient, as standardization of the PESI tool used only patients treated with subcutaneous Heparin (Aujesky et al., 2005).

Conclusion

The PESI tool can be useful in the clinical decision making process when working with patients diagnosed with acute PE. When coupled with good clinical reasoning and collaboration with the interprofessional care team and the ordering physician, the PESI score may be used to safely increase early mobilization, facilitate the return to ADL performance, shorten length of stay, and decrease patient mortality.

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About the Author

Michelle de la Garza OTD, OTR/L lives in Omaha, Nebraska and is a graduate from Creighton University.  She currently practices in an acute care hospital, as well as is involved with lab instruction for the Creighton University entry level OTD program.

References

Aujesky, D., Obrosky, D.S., Stone, R.A., Auble, T.E., Perier, A., Cornuz, J., … Fine, M.J. (2005). Derivation and Validation of a Prognostic Model for Pulmonary Embolism.

American Journal of Respiratory and Critical Care Medicine, 172, 1041-1046. DOI: 10.1164/rccm.200506-862OC.

Blattler, W & Partsch, H. (2003). Leg Compressions and Ambulation is Better Than Bedrest for the Treatment of Acute Deep Venous Thrombosis. International Angiology, 22(4), 393-400.

Centers for Disease Control and Prevention. (2014, December 10). Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)- Blood Clots Forming in a Vein: Data & Statistics. Retrieved from http://www.cdc.gov/ncbddd/dvt/data.html

Fraga, M., Taffe, P., Mean, M., Hugli, O., Witzig, S., Waeber, G., & Aujesky, D. (2010). The Inter-Rater Reliability of the Pulmonary Embolism Severity Index. Thrombosis and Haemostasis, 104, 1258-1262. DOI:10.1160/TH10-07-0426

Kahn, S.R., Shrier, I., & Kearon, C. (2008). Physical Activity in Patients with Deep Vein Thrombosis: A Systematic Review. Thrombosis Research, 122, 763-773. DOI:10.1016/j.thromres.2007.10.011

National Institutes of Health. (2011, July 1). Who Is at Risk for Pulmonary Embolism? Retrieved from http://www.nhlbi.nih.gov/health/health-topics/topics/pe/atrisk

Othieno, R., Abu Affan, M., & Okpo, E. (2007). Home Versus In-patient Treatment for Deep Vein Thrombosis. Cochrane Database of Systemic Reviews, 3, 1-28. DOI: 10.1002/14651858.CD003076.pub2

Riera-Mestre, A., Becattini, C., Giustozzi, M,. & Agnelli, G. (2014). Thrombolysis in Hemodynamically Stable Patients with Acute Pulmonary Embolism: A Meta-Analysis. Thrombosis Research, 134, 1265-1271. DOI: 10.1016/j.thromres.2014.10.004

Yoo, H.H.B., Queluz, T.H.A.T, & El Dib, R. (2014). Outpatient Versus Inpatient Treatment for Acute Pulmonary Embolism. Cochrane Database of Systematic Reviews, 11, 1-33. DOI:10.1002/14651858.CD010019.pub2

 

Patient Management and Prioritization in the ICU: A Model for Consideration

Occupational Therapy’s Distinct Value in the Intensive Care Unit (ICU)

Many might pose the question “What is occupational therapy’s (OT’s) distinct value in the ICU setting?” OT plays an important role in facilitating early mobilization, restoring function, preventing further decline, and coordinating care—including transition and discharge planning.

OT offers a unique perspective and focuses on a holistic view, in which many factors can influence the success of a patient’s recovery and rehabilitation process. “OT practitioners believe that intervention provided for people with physical disabilities should extend beyond a focus on recovery of physical skills and address the person’s engagement, or active participation, in occupation” (American Occupational Therapy Association, 2008). OT uses a systematic process of client-centered evaluation, intervention, and task modification to facilitate progress toward performance-based goals. This process begins by identifying activities the client needs and/or wants to do, as well as analyzing pre-hospitalization role and determining the supportive abilities or barriers to participating in those activities/roles.

In the critical care setting, OT practitioners perform a variety of skilled evaluations and interventions, which are essential to long-term patient wellness post-ICU discharge. The following are some examples of OT interventions in the ICU setting:

  • Evaluate the need for splints and other positioning devices to preserve joint integrity and decrease risk for skin breakdown due to prolonged pressure from bed rest;
  • Perform bedside evaluations to promote safety with eating and swallowing;
  • Train families and caregivers to assist with range-of-motion exercises, safe transfers and mobility, and skin checks;
  • Educate patients on post-surgical protocols, including appropriate weight bearing and other post-surgical precautions during activities of daily living (ADLs);
  • Teach compensatory strategies/techniques and use of adaptive equipment for maximizing independence with ADL function (i.e. teaching hemi-dressing technique after stroke to improve independence with upper extremity dressing, educating energy conservation techniques during ADL performance while patient is on the ventilator, teaching the use of a adaptive feeding utensils to improve feeding independence of a patient with poor grip strength after prolonged bed rest in the ICU);
  • Develop exercise programs and instruct patients, family members, and caregivers in how to use the programs during their ICU stay;
  • Fabricate or provide assistive devices and train patients in their use to promote healing and maximize independence;
  • Teach specific techniques for safety during functional mobility;
  • Teach stress management techniques and the development of coping skills;
  • Evaluate and treat ICU-acquired neurological-cognitive impairment (executive functioning, memory, and attention) to improve functional occupation-based outcomes;
  • Recommend home safety modifications and durable medical equipment during discharge planning.

In addition, OT practitioners understand the interplay between the patient’s needs, abilities, and environment, which assists with the patient’s successful transition to the home, community, or next level of care. OT programs in the ICU can alleviate some of the problems of isolation, sensory and occupational deprivation, and cognitive inactivity, which are risks to long-term wellness. ADL programs, including bed mobility, functional transfers to the commode or toilet, sitting tolerance, and light hygiene can restore a sense of daily routine and personal independence. These programs can also include relaxation techniques in combination with reality-orienting programs to provide organized, patterned stimulation and to develop an increased sense of control. These individualized programs can use client-centered, meaningful tasks to promote cognitive and motor recovery in patients (Affleck, Lieberman, Polon, & Rohrkemper, 1986; AOTA, 2014; Brummel et al., 2012; Brummel et al., 2013; Foreman, J., 2005; Hogan-Kelley, D., 2007; Schweickert et al., 2009).

Acquired Physical and Cognitive Impairment in the ICU

Patients who experience critical illness in ICUs are likely to acquire long-term physical and cognitive impairments, which affect the patient’s ability to function autonomously after discharge from the hospital. Due to bed rest and prolonged immobilization as well as increased use of sedation, patients can develop ICU-acquired weakness and motor/sensory neuromyopathy; sensory deprivation and stress; increased ventilator-dependent days; development of secondary medical complications, such as blood clots, pneumonia, and pressure ulcers; and acute brain dysfunction, manifesting as either delirium or coma. Therefore, occupational therapy has value in this setting and can assist in minimizing these complications.

Long-term physical impairment affects between 25% and 60% of ICU survivors. In addition to physical dysfunction, long-term cognitive impairment can be observed in one half to three fourths or more of ICU survivors. More specifically, delirium – defined as an acute change in mental status and fluctuating course of inattention and disorganized thinking – affects 60% to 80% of patients who are mechanically ventilated and is associated with several adverse outcomes including: prolonged mechanical ventilation, delayed hospital discharge, an increased risk of mortality, and long-term cognitive impairment (Brummel et al., 2012; Brummel et al., 2013; Mendez-Tellez, Nusr, Feldman, and Needham, 2012). Since many patients experience cognitive impairment in addition to physical complications when in the ICU, occupational therapy—in addition to physical therapy—should be incorporated into ICU programs and research studies.

Benefits of Early Rehabilitation in the ICU

Whole-body rehabilitation programs in the ICU—consisting of interruption of daily sedation combined with physical and occupational therapy in the earliest days of critical illness—are safe and well tolerated and result in better functional outcomes at hospital discharge, a shortening of delirium duration, fewer days on the ventilator compared to standard care, and decreased risk of mortality and re-hospitalization (Brummel et al., 2012; Brummel et al., 2013; Mendez-Tellez, Nusr, Feldman, and Needham, 2012).

These early rehabilitation programs demonstrate cost-saving data. One study outlined a length of stay reduction of 22% in the ICU and 19% reduction for the floor patients with a cost-savings of $817, 836. In this study a financial model projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. The projected net cost of implementing an ICU early rehabilitation program is modest relative to the substantial improvements in patient outcomes and cost-saving measures related to decreased length of stays, reduced number of days on the ventilator, and a decreased rate of re-hospitalizations (Lord et al., 2013).

A Peek into the ICUs at the University of Colorado Hospital

The OT department at the University of Colorado Hospital (UCH) strives to advocate for OT services in its six ICUs—neurological (24 beds), medical (24 beds), surgical (10 beds), cardiothoracic (17 beds), burn/trauma (9 beds), and cardiac (12 beds). The OT department recognizes the potential for overlap of services with other disciplines, particularly physical and speech therapy; however, OT is able to differentiate their role among other disciplines and highlight the distinct value of their services to patients and other health care personnel through sound clinical reasoning, appropriate timing of intervention, and occupation-based intervention tailored to patient and family. OT at UCH focuses on any functional deficit that will improve with OT intervention, such as ADL retraining; cognitive, vision, and sensory screening/assessment/treatment; upper extremity splinting, and establishment of routine to maximize functional independence.

When deciding which patients to treat in the ICU setting, the OTs developed an ICU triage system to improve the focus of OT, improve consistency among practitioners, and increase efficiency. The following characteristics have been identified as important for consideration when prioritizing ICU patients:

  • Acute rehabilitation candidacy;
  • Patients who are pending discharge;
  • Ventricular assistive device candidates (VAD) who need pre and post-VAD placement screening for identification of possible brachioplexus injuries, cognitive impairment, and UE dysfunction to determine if the patient will be able to manage the VAD post-operatively;
  • Patients after lung transplant (screening for possible radial nerve injury);
  • Patients with neurological and orthopedic issues (need to be acknowledged, screened, and charted on within 36 hours of initial OT order);
  • Patients with forearm free flaps, for splinting and follow-up
  • Patients with prolonged time on the ventilator (>3 days), general prolonged ICU stay (>3 days), or with greater than three chronic conditions (Hobbs, Boysen, McGarry, Thompson, & Nordrum, 2010).

The OTs at UCH evaluate patients status post coronary artery bypass grafts, aortic valve replacements, mitral valve replacements, video-assisted thoracic surgery, and Whipple procedure on post-operative day two as through practice based evidence it was determined these patients were mostly limited by post-operative pain, cognitive issues related to pain medication with subsequent difficulty remembering precautions instructed on post-operative day one, and numerous lines/tubes limiting what the OT could do on the first day after surgery (i.e. Swan Ganz Cathetor). Therefore, these patients were better suited to be evaluated and treated on post-operative day two.

When determining type of treatment the OT will facilitate in the ICUs at UCH, the Richmond Agitation Sedation Scale (RASS) is used as a guide for treatment. Each level of the RASS scale correlates to a specific treatment regimen. For example, if the patient has a RASS score of -3 or -2, which is moderate to light sedation and movement and eye opening to voice, the OT may perform guided active range of motion/active assist range of motion, ADL retraining (i.e. basic grooming) in bed to chair position, and initiate cognitive re-training (i.e. call light training, basic card game to improve attention, etc.). In addition, if patient scores a 0 or +1 on RASS scale, which is alert and calm or restless, the OT focus may be ADLs in bathroom seated or standing; instrumental activities of daily living (IADLs), such as medication management, financial management, self-care strategies; OT functional cognitive screen (Cognistat, Montreal Cognitive Screen, or Allen’s Cognitive Level Screen), and cognitive behavioral retraining (Ely et al., 2003; Sesslar et al., 2002).

UCH has established an ICU Progressive Mobility Program for nurses to assist with mobilization of patients. The nurses are responsible for following this protocol to determine at which level their patient should be mobilizing, such as positioning patient in chair mode in bed, sitting edge of bed, transferring to chair, and ambulating around room/unit. The nurses are provided with inclusion criteria for mobilization, including neurologic, respiratory, and cardiac stability as well as exclusion criteria including but not limited to unstable intracranial pressure (ICP) or presence of femoral sheaths (Perme & Chandrashekar, 2009; Timmerman, R.A., 2007) . The progressive mobility program allows OTs and PTs to focus on treatment beyond the scope of routine mobilization of each patient.

To maximize safety during OT intervention, UCH has recently developed an ICU competency program for new staff members. Ideally, the OTs will mentor a trainee for approximately three months and be available to answer any ICU-related questions. The ICU therapists (PTs and OTs) have developed an ICU Skills Check List so that the trainee has to identify each line (i.e. standard monitoring, tubes, ICP monitoring, cardiac support devices, oxygen delivery devices, and mechanical ventilation). The trainee also has to understand hemodynamic monitoring, delirium/sedation monitoring, and common medications used in the ICU.

Conclusion

It is encouraged to consider use of the ICU program at UCH as a model for the development of both early rehabilitation programs and patient management. OT has a distinct and valuable role in the ICU setting – facilitating minimization of physical and cognitive impairment as well as optimization of overall functional patient outcomes, while reducing institutional financial burden. It is essential that OTs advocate for their role in early ICU intervention programs in their respective hospitals in order to ensure that the value of OT is not overlooked; and more importantly, so that patients receive comprehensive, quality care as they begin their journey to recovery.

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About the Author

Melissa Sixta, OTD, OTR/L is an occupational therapist at the University of Colorado Hospital (UCH), which is a 568-bed teaching hospital in Aurora, CO. Melissa graduated with her Doctorate in Occupational Therapy at Creighton University in Omaha, NE in 2009. She has experience working in acute care, sub acute and acute rehabilitation, and outpatient therapy. Melissa is currently the Student Program Coordinator at UCH. She is also the Public Policy Chair and Board Member for Occupational Therapy Association of Colorado (OTAC). In 2013 she was on the Legislative Committee of which contributed to passage of licensure for occupational therapy practitioners in Colorado. She is published in the Journal of Neurotherapy, OT Practice, and has contributed to a chapter in OT Manager.

References

  1. American Occupational Therapy Association. (2008). Occupational therapy’s role in acute care. Retrieved from aota.org.
  2. Affleck, A.T., Lieberman, S., Polon, J., & Rohrkemper., K. (1986). Providing occupational therapy in the intensive care unit. AJOT. 40(5). 323-332.
  3. Brummel, N.E., Girard, T.D., Ely, E.W., Pandharipande, P.P., Morandi, A., Hughes, C.G., Jackson, C.G. (2013). Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: The activity and cognitive therapy in ICU trial. Intensive Care Medicine.
  4. Brummel, N.E., Jackson, J.C., Girard, T.D., Pandharipande, P.P., Schiro, E., Work, B., … Ely., W. (2012). A combined early cognitive and physical rehabilitation program for people who are critically ill: The activity and cognitive therapy in the intensive care unit (ACT-ICU) trial. PT Journal. 92(12); 1-13.
  5. Ely, E.W., Truman, B., Shintani, A., Thomason, J.W., Wheeler, A.P., & Gordon, S. (2003). Monitoring sedation over time in ICU patients: The reliability and validity of the Richmond agitation sedation scale (RASS). JAMA. 289; 2983-2991.
  6. Foreman, J. (2005). Occupational therapists’ roles in intensive care. OT Now. 15-18.
  7. Hobbs, J., Boysen, J., McGarry, K., Thompson, J., & Nordrum, J. (2010). Development of a unique triage system for acute care physical therapy and occupational therapy services: An administrative case report. Physical Therapy. 90; 1519-1529.
  8. Hogan-Kelley, D. (2007). Occupational therapy frames of reference for treatment in the ICU. Retreived from aota.org.
  9. Lord, R.K., Mayhew, C.R., Korupolu, R., Mantheiy, E.C., Friedman, M.A., Palmer, J.B., & Needham, D.M. (2013). ICU early physical rehabilitation programs: A financial modeling of cost savings. Critical Care Medicine. 41(3); 717-724.
  10. Mendez-Tellez, P.A., Nusr, R., Feldman, D. & Needham, D.M. (2012) Early rehabilitation in the ICU: A review for the neurohospitalist. The Neurohospitalist. 2(3); 96-105.
  11. Perme, C., Chandrashekar, R. (2009). Early mobility and walking program for patients in intensive care units: creating a standard of care, AJCC, 18(3); 212-21.
  12. Sessler, C.N., Gosnell, M., Grap, M.J., Brophy, G.T., O’Neal, P.V., & Keane, K. A. (2002). The Richmond agitation-sedation scale: Validity and reliability in adult intensive care patients. American Journal of Respiratory Critical Care Medicine. 166; 1338-1344.
  13. Schweickert, W.D., Pohlman, M.C., Pohlman, A., Nigos, C., Pawlik, A.J., Esbrook, C.L., Kress, J.P. (2009). The Lancet. 373 (9678); 1874-1882.
  14. Timmerman, R.A. (2007). A mobility protocol for critically ill adults. Dimens Crit Care Nurs, 26(5); 175-9.

 

The Core Values of Occupational Therapy: Supported by Evidence-Based Task-Oriented Training for Clients with Stroke

By: Sara E. Benham, OTD, OTR/L, ATP

Upper extremity impairment is a strong focus of occupational therapy treatment for clients who have experienced stroke. It is estimated that there are over 700,000 incidents of stroke in the United States each year with 4.8 million stroke survivors alive today (AHA, 2003). Approximately 70-80% of the survivors experience upper extremity impairment (Parker, Wade, & Hewer, 1986) which impacts occupational participation. Driven by AOTA’s Centennial Vision (AOTA, 2007) members are motivated to meet the occupational needs of clients with science-driven and evidence-based interventions. Occupational therapists have multiple treatment options from which to choose regarding upper extremity impairment mitigation. Recent high-level evidence from randomized control trials (RCTs) has supported novel approaches, such as robot-assisted therapy (Wu, Yang, Chuang, Lin, Chen, Chen, & Huang, 2012) and constraint-induced movement therapy (CIMT) (Wolf, Thompson, Winstein, Miller, Blanton, Nichols-Larsen, Morris, Uswatte, Taub, Light, & Sawaki, 2010). Emerging neuroplasticity-based exercise treatments may address and improve impairment; however occupational therapy long-term goals are usually related to the client’s participation in occupation. Task-oriented training is an intervention that focuses directly on client-centered participation in functional activities.

While task-oriented training may be more aligned with the values of occupational therapy (AOTA, 2008), clients may expect to participate in traditional and potentially beneficial exercise and strength training. Motivated by the profession’s core values to integrate task-oriented occupation, this author completed a Critically Appraised Topic (CAT) focusing on how task-oriented training compares with traditional strength training to improve upper extremity function for persons with stroke. It is important to note the limitation of this CAT: It has been individually prepared and not peer-reviewed.

A focused clinical question guided the CAT: Among people with unilateral upper extremity hemiparesis, how does task-oriented upper extremity treatment compare with upper extremity strength training on improving functional upper extremity motor return as measured on the Wolf Motor Function Test (WMFT), the Fugl-Meyer (FM), and/or the Functional Test of the Hemiparetic Upper Extremity (FTHUE)? The question was summarized from a PICO question (Patient, Intervention, Comparison, and Outcome) (Lou & Durando, 2008) to intentionally guide a client-centered search for the accurate, relevant, and high-quality evidence. Clinicians should seek the highest-quality evidence from a systematic review rather than a primary RCT, if it is available.

The CAT summarized a total of five relevant, Level I studies that included two systematic reviews. A study that investigated task-oriented training as compared to strength training was identified as ‘best evidence’ because it directly related to the PICO question (Winstein, Rose, Tan, Lewthwaite, Chui, & Azen, 2004). Both functional task practice and strength training (in addition to standard occupational therapy sessions) are superior to standard occupational therapy alone with regard to improvements in functional impairment and strength. Subjects with less stroke severity demonstrated greater improvements in both functional task practice and strength training groups. Subjects who participated in functional task training continued to improve strength at follow-up.

Two publications included in the CAT concluded that task-oriented training is an effective intervention to improve functional upper extremity performance for individuals with stroke (Timmermans, Spooren, Kingma, & Seelen, 2010) at post-intervention and follow-up (Arya, Verma, Garg, Sharma, Monia, & Aggarwal, 2012). With regard to strength training, one publication concluded that it is an effective intervention to improve grip strength and upper extremity function for individuals with stroke, however does not improve ADL performance. (Harris & Eng, 2010). Another randomized control trial concluded that self-directed exercise was effective with statistical significance to improve functional use of the upper extremity at post-intervention for subjects with chronic stroke. The amount of improvement was comparable to other novel treatment approaches previously mentioned such as CIMT and robot-aided exercise training (Pang, Harris, & Eng, 2006).

The clinical bottom line is that both task-oriented training and strength training are effective treatment interventions to improve upper extremity function after stroke. The evidence suggests that task-oriented training contributes to greater functional long-term results. Emerging evidence supports task-oriented training that includes clear functional goals and random practice components to improve functional performance at follow-up (Timmermans, Spooren, Kingma, & Seelen, 2010). These findings are most significant for clients who demonstrate mild to moderate upper extremity functional impairments.

These findings support that client-directed occupational therapy treatment with a functional task focus is an effective intervention for clients with stroke. The profession of occupational therapy is built on solid principles that support goal-directed functional participation. Therefore, it seems intuitive for occupational therapists to integrate functional, task-oriented practice in neurological treatment interventions. The advantages are easy to see: The intervention is cost-effective, statistically significant, and can be applied in any treatment setting. However, the potential disadvantages of occupational therapists overlooking the consistent utilization of task-oriented treatment may be detrimental in the near future. In an editorial of the Journal of American Physical Therapy Association, Jette and Latham (2011) reported that “task-oriented training is significantly more effective at improving function than standard impairment-focused training” (p. 1709). Now, the American Physical Therapy Association’s guidelines for practice include the alleviation of impairment and functional limitation, including “functional training in self-care and home management” (APTA, 2011, p. 57). As we progress toward the Centennial Vision of 2017, it is imperative for occupational therapists to meet society’s occupational needs. It is the responsibility of every occupational therapist to protect our unique contribution of integrating occupational, task-oriented treatment in upper extremity impairment mitigation.

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About the Author

Sara Benham, OTD, OTR/L, ATP is presently assistant professor at the University of the Sciences in Philadelphia. She graduated with her master’s degree in occupational therapy from the University of Indianapolis in 2006, and in 2014, obtained her doctorate degree in occupational therapy from Thomas Jefferson University.  She has 8 years experience in rehabilitation; in addition, her specialization is in assistive technology and stroke rehabilitation. She obtained an advanced certification in assistive technology from the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).  She has instructed an OT neuro-rehabilitation course for a rehab technician program in Haiti in the recent past. She presented at the Annual AOTA Conference in Baltimore on wellness apps appropriate for clients in an inpatient rehabilitation program.

References

  1. American Heart Association. (2003). Heart Disease and Stroke Statistics: 2004 Update. Dallas, TX: American Heart Association.
  2. Parker, V. M., Wade, D. T., Hewer, R. L. (1986). Loss of arm function after stroke: Measurement, frequency, and recovery. International Rehabilitation Medicine, 8 (2), 69-73.
  3. American Occupational Therapy Association. (2007). AOTA’s centennial vision and executive summary. American Journal of Occupational Therapy, 61(6), 613-614.
  4. Wu, C., Yang, C., Chuang, L., Lin, K., Chen, H., Chen, M., & Huang, W. (2012). Effect of therapist-based versus robot-assisted bilateral arm training on motor control, functional performance, and quality of life after chronic stroke: a clinical trial. Physical Therapy, 92(8), 1006-1016.
  5. Wolf, S. L, Thompson, P. A., Winstein, C. J., Miller, J. P., Blanton, S. R., Nichols-Larsen, D. S., Morris, D. M., Uswatte, G., Taub, E., Light, K. E., & Sawaki, L. (2010). The EXCITE stroke trial: Comparing early and delayed constraint-induced movement therapy. Stroke, 41, 2309-2315.
  6. American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.
  7. Lou, J. Q. & Durando, P. (2008). Asking clinical questions and searching for the evidence. In M. Law & J. MacDermid (Eds.), Evidence-based rehabilitation: A guide to practice (2nd ed.) (pp. 92-117). Thorofare, NJ: SLACK.
  8. Winstein, C. J., Rose, D. K., Tan, S. M., Lewthwaite, R., Chui, H. C., Azen, S. P. (2004). A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: A pilor study of immediate and long-term outcomes. Archives of Physical Medicine and Rehabilitation, 85, 620-628.
  9. Timmermans, A. A., Spooren, A. I., Kingma, H., Seelen, H. A. (2010). Influence of task-oriented training content on skilled arm-hand performance in stroke: A systematic review. Neurorehabilitation and Neural Repair, 24(9), 858-870.
  10. Arya, K. N., Verma, R., Garg, R. K., Sharma, V. P., Aggarwal, M., & Aggarwal, G. G. (2012). Meaningful task-specific training (MTST) for stroke rehabilitation: A randomized controlled trial. Topics in Stroke Rehabilitation, 19(3), 193-211.
  11. Harris, J. E. & Eng, J. J. (2010). Strength training improves upper-limb function in individuals with stroke. Stroke, 41, 136-140.
  12. Pang, M. Y. C., Harris, J. E, & Eng, J. J. (2006). A community-based group upper extremity exercise program improves motor function and performance of functional activities in chronic stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 87(1), 1-9.
  13. Jette, A. M. & Latham, N. K. Disability research: Progress made, opportunities for even greater gains. Journal of the American Physical Therapy Association, 91(12), 1708-1711.
  14. American Physical Therapy Association. (2011, January). Today’s physical therapist: A comprehensive review of a 21st-century health profession. Retrieved from http://www.apta.org/uploadedFiles/APTAorg/Practice_and_Patient_Care/
    PR_and_Marketing/Market_to_Professionals/TodaysPhysicalTherapist.pdf
  15. American Occupational Therapy Association. (2010). OT Practice author guidelines. Retrieved from http://www.aota.org/Pubs/Publish/40400.aspx
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