Ann: Hello everyone! I hope that all of you are using the Occupational Therapy Practice Framework (OTPF). I am sure those of you who finished school after 2002 have been using it. Those of us who graduated earlier grew up with a different taxonomy. The OTPF (2014) is the language that we currently speak. The OTPF was developed at the same time that the ICF, the International Classification of Functioning Disability and Health, was developed by the World Health Organization. When the OTPF was developed, there was a conscious effort to include words that describe the coding system that the international community uses and understands, so that our interventions and our assessments would be better understood and accepted.
Occupations/Client Factors
Occupations include activities of daily living, instrumental activities of daily living, rest and sleep, education, work, play, leisure, and social participation. The client factors are values, beliefs, spirituality, body functions, and body structures. Sometimes when we talk about older adults, body functions and body structures figure strongly into procedural reasoning, or the type of reasoning we use clinically when we are aware of comorbidities. We need to think about the different illnesses, the medications used to treat those illnesses, and how that might have an impact on how the person performs. For instance, in this particular presentation, the one that tends to be part of the OT domain of practice, but too often is left unassessed, is sensory functioning. We talk about sensory processing disorders, but we do not talk about peripheral sensory impairments as much. There has been documentation in the professional literature about the loss of sensation in older adults and the lack of assessment of it. Often, older adults have sensory impairments that go unchecked. Those of us who work with people that have sensory impairments are aware of the importance, especially if they are using sharp objects. They may not feel that they have cut themselves for instance.
In terms of values, beliefs, and spirituality, we know that people need to value what our participation is. I used to do service learning with the Native American community. Native American elders have participated in Think Tanks, like the Think Tank at Oxford University. Black Elk, an elder for the Lakota community, has pointed out in his talks and writings that Native Americans do not necessarily embrace Western concepts like regular medicine. This is important to know if you are an occupational therapist and working in a medical community. You need to make sure that what you are trying to do has meaning to the individual. Sometimes our knowledge of culture and beliefs helps the team as a whole, and that can be a unique contribution that we make in the interdisciplinary team.
Occupational Profile
I am also hoping that all of you are using the occupational profile as it is embedded into the OTPF.
The occupational profile is the initial step in the evaluation process which provides an understanding of the client’s occupational history and experiences, patterns of daily living, interests, values, and needs. The client’s reasons for seeking services, strengths and concerns in relation to performing occupations and daily life activities, areas of potential occupational disruption, supports and barriers, and priorities are also identified.
You can download a PDF of it to use. Many companies, that use electronic documentation systems, have it loaded into their documentation systems. Per the Centers of Medicare and Medicaid Services (1/1/17), we need to include the occupational profile with every client (AOTA evaluation coding). The OTPF takes into account the person and all of the usual things that we look at, but it also addresses their beliefs and culture. It frames the picture for the rest of the team.
Performance Skills
Performance skills are also part of the OTPF.
Motor Skills
- Gross mobility
- Core strength
- General strength
- Coordination
- Dexterity
- Sensory function
- Vestibular
- Visual
- Auditory
- Tactile
- Taste/smell
In motor skills, we often talk about gross mobility, which is the ability to move the body through space and against gravity. Core strength is the strength of the trunk muscles and the abdominal muscles, and the extensors and rotators of the back. We also look at general strength overall, which is often impaired when people receive medical treatments. For people that have cancer and chemotherapy, losing muscle can be a part of the problem. Another example is a person with HIV as it has a wasting component to it in terms of strength. Coordination is also important. This is how our eyes, hands, and minds work together to accomplish a task in a timely and efficient manner. Dexterity is using the hands and the fingers for fine motor control.
Sensory function includes many areas. Vestibular is balance. Visual is how our eyes are working. Auditory is hearing. Tactile function includes the rapidly adapting fibers as well as the slow adapting fibers of sensation, and protective sensation. If you are familiar with Dr. A. Lee Dellon's work in sensibility, he talks about the use of both the rapidly adapting and slow adapting fibers. He says it is important for people that are losing rapidly adapting fibers to still utilize the slow adapting fibers for protective sensation. Finally, there is taste and smell. Many adults, once they hit their sixth or seventh decade, begin to have difficulty with food smelling or tasting the same. This can also be a sign of disfunction. For example, the "olive" (olivary body) in the brain is an area where people can record tactile, taste, and smell. It allows a person to remember tastes and smells from the past. The olive records what feels and tastes good. When there are problems with taste and smell, then oftentimes people will not eat well, and they may begin to have problems with thriving.
Process Skills
These are observed as a person (1) selects, interacts with, and uses task tools and materials; (2) carries out individual actions and steps; and (3) modifies performance when problems are encountered. Process skills are part of the Assessment of Motor and Process skills, or the AMPS. I am certified in the AMPS and have used it clinically and in research in the past. Ann Fisher, who developed the AMPS, is part of the group that developed the OTPF. You see the words process and motor skills filtering through the OTPF. Process skills are the cognitive components that are very important to the fluidity of successful participation in occupations.
Social Interaction Skills
Then there are the social interaction skills. We are one of the few professions that focuses in on social interaction. It is an ongoing stream of social exchange. Barbara Boyt Schell is mentioned in the OTPF for this definition.
Strength Measurements
Many of these strength measurements you will have learned in school.
- Break Test
- Sit to Stand Test
- Dynamometer and pinch meter measurements
The Break Test is where you test the strength of a muscle three times. You apply matched resistance and try to get the person to hold the muscle, and then you take the average of the three performance pieces. The Break Test is more of a true test of strength. The Sit to Stand Test is also known as the Chair Stand Test. They are not allowed to use the arms of the chair or their hands on their legs when standing. From a 90/90 degree position of the hips and knees, you have the client stand five times at a pretty rapid pace. This is an indicator of the proximal musculature and strength, and the ability of the person to get up and out of a chair or a seated surface. You can judge their safety by their performance during that task as well. It also indicates to you if a person is having a loss of gross mobility. For instance, they may have decreased mobility due to back pain. Dynamometer and pinch meter measurements are key outcome measures. Virgil Mathiowetz and his team published the norms of dynamometer and pinch meter measurements for different ages. You will find the norm for the age you are addressing. Some studies have shown that a loss of hand strength, as measured on the Dynamometer, can be an indicator of cardiac functioning. So, if people have a very weak grasp as they age, and they do not have something like arthritis that precludes their ability to squeeze without pain, this may be an indication that they have cardiac issues that are underlying it.
Balance Measurements
Measures of balance include:
- Functional Reach Test
- Pull Test
- Foam and Dome
The Functional Reach Test is where you have a person stand adjacent to a wall and hold the arm, that is next to the wall, up with a clenched fist. You can note on the wall where the head of the third metacarpal is by putting a removable marker there, like a piece of masking tape or a colorful dot. Then from that point, you have them reach as far forward as they can until they feel as though they are losing their balance. You measure with their arm outstretched where their third metacarpal is again. You then compare the distance between the two markers. This gives you a reading for how far they can reach before they lose their balance. I have put a reference in for that at the end. You will also find multiple sites on the internet that describe how to do these standardized tests if you are not familiar with them. The Pull Test is often used by neurologists. You stand behind a person and then unexpectedly pull them backward. You see how many steps it takes for them to recover their balance. This has been shown to be very helpful with people with neurological disfunction, like Parkinson's Disease. Another test that was developed by a physical therapist is called the Foam and Dome Test. This is a little riskier. The low tech way of doing it is having the person stand on a piece of foam on the floor and occluding their vision. Again, I have noted in the bibliography the cardinal article for this that you can find through Google Scholar. Personally, I have used both the Functional Reach Test and the Pull Test in the NIH study that I did with Steven Albert and Jane Bear-Lehman.
How to Measure
How do we assess for change in the type and quantity of activities clients are doing relative to their IADLs, leisure, and social activities? The Activity Card Sort is a great tool if you are looking for an occupational therapy specific standardized scale that is used cross culturally. Different cultures are being added over time as not every cultural group engages in the same occupations. It is very useful in the community. I like it because the person has to attend to your voice auditorially, and it also provides a visual component as well. There are photographs of a number of different activities that older people are engaged in such as: taking out the garbage, washing dishes, maintaining personal finances, or participating in religious or leisure activities. One of the items is going to a restaurant. One population that I studied and worked with in northern Manhattan was a group of people from the Dominican Republic. I was amazed to learn that some of them had never been to a restaurant. This is something in the United States that we take for granted, but in different cultures, it may be appreciated in a different way. This activity helps you determine what is meaningful to them and what is less important. There are a huge number of activities. For this population, we used a portion of the photographs depicting urban dwelling older adults where there was adequate public transportation. Many of them rented their homes versus owning. Home maintenance does not have the same level as importance with this population as it would with a suburban or rural population. As you can see, many things may need to be adapted for your treatment population. The Activity Card Sort is published and sold through the AOTA, and it comes with a user manual as well. A discovery that a person is limiting their activities should trigger screenings for medical wellness. When we do the Activity Card Sort, we need to ask them specific questions. "When was the last time that you saw a physician?" "When was your vision tested last?"
Vision Screening
In the community, you can do screening with older adults yourself. There are Snellen charts available on the internet that you can download, and you stand a certain distance to assess their acuity, or sharpness of vision. There are also near cards that the person can use. You can attach a string to get the distance right.
You can also download the Amsler grid from the internet, and there is a link to that in the bibliography. The Amsler grid, if you are not familiar with it, is a series of lines going horizontally and vertically, almost like a woven pattern. You ask the person if they see any breaks in the line. If they see breaks in the line, it may indicate that they have a problem with macular degeneration. You may encounter people that have not been to an eye doctor for more than a decade. If you notice abnormalities on these tests, this is your opportunity to direct them back to get further screening and medical attention. With the proper medical attention like eye drops, laser treatments, or ocular injections, many of these progressive eye conditions can be slowed.
Perimetric screening, or bowl perimetry, is looking at the full field of vision and determining whether or not there is any loss within that field. People that have a cortical component to their visual problems will have difficulty with perimetry, and you will see a mapped out area within the visual field that shows where the visual loss is. Part of what our brain does to make us feel more calm is make up something if we have an area of cortical blindness so that is looks like a continuous pattern. Parametric screening helps those of us who are working with clients to see if they have areas of cortical blindness.
Oculomotor responses are what we test when we ask the person to fix their gaze and to not turn their head while moving their eyes in different directions. With this type of testing, we are looking for convergence and tracking. We also check their ability to have protective responses. For example, if something is moving toward them like a projectile, do they react to it appropriately because of a visual input? This involves the cranial nerves and how they innervate the muscles surrounding the eye. Another example is diplopia which often happens with a stroke. You can tease out the ocular motor responses and see problems as they are occurring. Sometimes you will see peripheral weakness as well. In Horner's Syndrome, they have a droopy eyelid, and you may see some slowed ocular motor responses. Sometimes people have had small strokes, and these ocular motor results might help identify that.
Finally, there is an object called the Pocket Held Illuminated Light Card. This mimics everything that an ophthamologist or an optometrist might do. The version that I have used in the past was invented by one of the ophthalmologists who I worked with at Columbia, who was a consultant to our study.
