Occupational therapists can provide a unique and critical role in the formation of the life care plan. Many of the pages of a life care plan fall under the domain of occupational therapy (OT). The ability to perform daily tasks of self-care, play, school, work, or social participation is the very core of the practice of OT as well as the basis for some of the contents of a life care plan.
The objective of OT is the essence of the purpose of a life care plan. “Occupational therapy helps people live life to its fullest. It does this by helping people of all ages who have suffered an illness, injury or some form of debilitation relearn the skills of daily living.
By focusing on the physical, psychological and social needs of its patients, OT helps people function at the highest possible level, concentrating on what’s important to them to rebuild their health, independence and self-esteem” (American Occupational Therapy Association [AOTA], 2008).
Indeed, the AOTA has brought forward a brand to market what OT has to offer consumers. This brand is “Living Life to Its Fullest” (OT Practice, 2008). President of AOTA, Penelope Moyers Cleveland, said, “The key take away we want everyone to have is that living life and occupational therapy are inextricably linked” (p. 7).
Several philosophical assumptions are presented to guide OTs in their profession. The assumptions that parallel those of the life care planner are (Atchinson & Dirette, 2007, p. 3):
¦ “Each individual has a right to a meaningful existence: the right to live in surroundings that are safe, supportive, comfortable, and over which he or she has some control; to make decisions for himself or herself; to be productive; to experience pleasure and joy; to love and be loved.”
¦ “Each individual has the right to reach his or her potential through purposeful interaction with the human and nonhuman environment.”
¦ “The extent to which intervention is focused on the context, the areas of occupational performance or on the client depends on the needs of the particular individual at any given time.”
The Occupational Therapy Practice Framework (2002) reports, “Occupational therapy’s domain stems from the profession’s interest in human being’s ability to engage in everyday life activities.” The broad term that OTs and assistants use to capture the breadth and meaning of “everyday life activities is occupation” (p. 610). The Framework goes on to identify the OT assessment process: “The initial step in the evaluation process provides an understanding of the client’s occupational history and experiences, patterns of daily living, interests, values, and needs, the client’s problems and concerns about performing occupation and daily life activities are identified and the client’s priorities are determined” (p. 614). This is in harmony with the approach of the life care planner in determining numerous contents of a life care plan.
Occupational Therapy Assessment Tools: An Annotated Index (2007) reviews almost 400 instruments used for evaluation by OTs. Evaluation tools reflect the broad scope of OT. The contents of the Index lists assessment tools in the following areas: occupational performance; activities of
daily living and instrumental activities of daily living; vocation; play; leisure; social participation and quality of life; developmental skills; motor skills; perception; sensory; assessments of social interaction; cognitive assessments; psychological assessments; roles, habits, and routines; coping and adaptive behaviors; assessments of disability status; and assessments of home and work environments {pp. iii—xvi). Clearly, it is beyond the scope of this post to review all of these assessment tools. Use of a particular instrument is likely to vary by region of the country and OT subspecialty, and it is unlikely any OT will have expertise in administration and knowledge of interpretation of all of these measures. Some of the more frequently used evaluation tools are provided here:
¦ Canadian Occupational Performance Measure (COPM), 4th edition {2005, originally published 1991)
Purpose: This individualized clinical outcome measure was designed to detect change in a client’s self-perception of occupational performance over time. The COPM fosters collaboration between the client and the OT to design intervention (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 33).
¦ FIM System and WeeFIM System II (includes 0-to-3 module) (revised from the Functional Independence Measure and Functional Independence Measure for Children) (FIM developed in 1984, version 5.1 in 1997; WeeFIM developed in 1987, version 6.0 in 2006)
Purpose: The Uniform Data System for Medical Rehabilitation (UDSMR) is a nonprofit organization that promotes uniform documentation of the severity of patient disability and the results of medical rehabilitation. At the core of the UDSMR is the Uniform Data Set, which includes FIM and WeeFIM for assessing severity of disability. They are used as measures of functional status and reflect the impact of disability on the individual and on the human and economic resources of the community. FIM and WeeFIM are designed for clinical evaluation of the individual and to generate group data and analyze the outcomes of rehabilitation in terms of burden of care. The WeeFIM II 0-to-3 Module measures precursors to function in children 0 to 3 years of age as well as changes over time (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 80).
¦ Kohlman Evaluation of Living Skills, 3rd edition (KELS) (1992)
Purpose: This tool is designed to provide a quick and simple evaluation of a person’s ability to perform basic living skills. Although not comprehensive, it can help determine degree of client’s independence and suggest appropriate living situations that will maximize independence (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 102).
¦ WorkWell Systems FCE, version 2 (2006)
Purpose: This WorkWell instrument is designed to identify maximum safe work abilities and any limitations that prevent safe return to work and to provide recommendations to assist safe return to work (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 174).
¦ Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley III; including the Bayley-III Motor Scale and Bayley-III Screening Test) (2005)
Purpose: The comprehensive scales are designed to identify children who have delays in multiple developmental areas, provide baseline information for planning interventions, and follow progress (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 244).
¦ Peabody Developmental Motor Scales, 2nd edition (PDMS-2) (2000)
Purpose: This motor development program provides in-depth assessment as well as training and remediation of gross and fine motor skills. It can be used for research and to measure a person’s motor competence relative to peers, qualitative and quantitative aspects of skills, skill deficits, and progress over time (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 329).
¦ The Nine-Hole Peg Test (1985)
Purpose: This tool is used to measure unilateral finger dexterity to determine the extent of fine motor impairment in people experiencing difficulties with functional performance (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 324).
¦ Motor-Free Visual Perception Test, 3rd edition (MVPT-3); Motor-Free Visual Perception Test, vertical format (MVPT-V) (MVPT-3, 1972, revised 1995, 2003; MVPT-V, 1995)
Purpose: The MVPT-3 was designed to provide a quick and simple evaluation of visual perception that avoids motor involvement by the subject. It may be used in screening, diagnosis, and research. The third edition was revised to expand the test population to adolescents and adults. The MVPT-V allows evaluation in subjects with spatial deficits due to hemifield visual neglect (HVN) or abnormal visual saccades (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 385).
¦ Test of Visual-Motor Integration (TVMI) (1996)
Purpose: The TVMI was designed to be an objective, valid test of visual-motor integration skills, examining how a child interprets, organizes, and replicates physical elements of a stimulus. It can be used for screening, evaluation, research, and diagnostic purposes (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 408).
¦ Sensory Profile (SP): Adolescent/Adult SP, Infant/Toddler SP (1999; 2006 School Companion)
Purpose: The SP is designed to measure responses to sensory events in everyday life that support or interfere with function. Children’s versions allow caregiver’s observations to be used in conjunction with other evaluations, reports, and observations from critical members of the team. The version for adolescents and adults allows the subject to identify personal behavioral responses to everyday sensory experiences and patterns and strategies that promote daily function in the environment. The School Companion incorporates the teacher’s perspective on the child’s interaction in an academic environment (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 442).
¦ Allen Cognitive Level Test (ACL-90) (1990)
Purpose: The ACL-90 is a brief screening test to estimate the client’s cognitive functioning and capacity to learn and to guide treatment goal setting. Cognitive function categories are based on
the author’s theoretical hierarchy of cognitive levels of function (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 491).
¦ Pediatric Evaluation of Disability Inventory (PEDI) (1992)
Purpose: The PEDI is a comprehensive clinical assessment of functional capabilities and typical performance in young children with disabilities. It is used to detect functional deficits, monitor progress, or evaluate the outcome of a therapeutic program. PEDI includes a Modifications scale and Caregiver Assistance scale to determine the level of adaptation and assistance required for performance (Occupational Therapy Assessment Tools: An Annotated Index, 2007, p. 698).
The performance of activities of daily living (ADL) has long been the cornerstone and domain of the OT. While typical self-care skills of dressing, eating, and bathing are often associated with the profession, the scope of ADL is significantly greater. The Occupational Therapy Practice Framework: Domain and Process (2002) provides the detail (p. 620):
¦ Bathing, Showering: Obtaining and using supplies; soaping, rinsing, and drying body parts; maintaining bathing position; and transferring to and from bathing positions (Uniform Data System for Medical Rehabilitation [UDSMR], 1996, pp. III—20, III—24).
¦ Dressing: Selecting clothing and accessories appropriate to time of day, weather, and occasion; obtaining clothing from storage area; dressing and undressing in a sequential fashion; fastening and adjusting clothing and shoes; and applying and removing personal devices, prostheses, or orthoses.
¦ Eating: “The ability to keep and manipulate food/fluid in the mouth and swallow it” (O’Sullivan, 1995, p. 191, as cited in AOTA, 2000, p. 629).
¦ Feeding: “The process of [setting up, arranging, and] bringing food [fluids] from the plate or cup to the mouth” (O’Sullivan, 1995, p. 191, as cited in AOTA, 2000, p. 629).
¦ Functional Mobility: Moving from one position or place to another (during performance of everyday activities), such as in-bed mobility, wheelchair mobility, and transfers (e.g., to and from a wheelchair, bed, car, tub, toilet, tub/shower, chair, or floor). Performing functional ambulation and transporting objects.
¦ Personal Device Care: Using, cleaning, and maintaining personal care items, such as hearing aids, contact lenses, glasses, orthotics, prosthetics, adaptive equipment, and contraceptive and sexual devices (also see Sexual Activity below).
¦ Personal Hygiene and Grooming: Obtaining and using supplies; removing body hair (use of razors, tweezers, lotions, etc.); applying and removing cosmetics; washing, drying, combing, styling, brushing, and trimming hair; caring for nails (hands and feet); caring for skin, ears, eyes, and nose; applying deodorant; cleaning mouth; brushing and flossing teeth; or removing, cleaning, and reinserting dental orthotics and prosthetics.
¦ Sexual Activity: Engagement in activities that result in sexual satisfaction.
¦ Sleep/Rest: A period of inactivity in which one may or may not suspend consciousness.
¦ Toilet Hygiene: Obtaining and using supplies; clothing management; maintaining toileting position; transferring to and from toileting position; cleaning body; and caring for menstrual and continence needs (including catheters, colostomies, and suppository management).
Maneuver power/manual wheelchair (note if Quad pegs/one hand/joystick/sip & puff, etc.)Transfer from chair to vehicleUse lap board/bag/caddy/ashtrayReposition in chair with/without assistanceNegotiate rough/smooth terrainUpper extremities orthotics/braces off/onUpper extremities prosthetics off/onLower extremity prosthetics on/offLower extremity orthotics/braces on/offPERSONNEL/ATTENDANT CARE NEEDSNeeds companion for judgment (due to TBI)Needs guardian (incl. money management)Occasional (e.g., morning/eve/weekends)Live-in attendant (10-12 hours per day and night safety)24-hour skilled/high-tech awakeHouse maintenance interior/exteriorSource: Roger O. Weed.
Hinojosa and Blout (2004) describe instrumental activities of daily living (IADL) as “complex multi-step activities requiring the integration of higher level cognitive skills (e.g., meal preparation, money management, community travel)” (p. 447). The authors report that these skills are needed to “participate in complex social relationships and societal organizations” (p. 447). The Occupational Therapy Practice Framework: Domain and Process (2002) provides the detail of what is included in IADL (p. 620):
¦ Care of others (including selecting and supervising caregivers): Arranging, supervising, or providing the care for others.
¦ Care of pets: Arranging, supervising, or providing the care for pets and service animals.
¦ Child rearing: Providing the care and supervision to support the developmental needs of a child.
¦ Communication device use: Using equipment or systems such as writing equipment, telephones, typewriters, computers, communication boards, call lights, emergency systems, Braille writers, telecommunication devices for people with deafness, and augmentative communication systems to send and receive information.
¦ Community mobility: Moving self in the community and using public or private transportation, such as driving, or accessing buses, taxi cabs, or other public transportation systems.
¦ Financial management: Using fiscal resources, including alternate methods of financial transaction and planning and using finances with long-term and short-term goals.
¦ Health management and maintenance: Developing, managing, and maintaining routines for health and wellness promotion, such as physical fitness, nutrition, decreasing health risk behaviors, and maintaining medication routines.
¦ Home establishment and management: Obtaining and maintaining personal and household possessions and environment (e.g., home, yard, garden, appliances, vehicles), including maintaining and repairing personal possessions (clothing and household items) and knowing how to seek help or whom to contact.
¦ Meal preparation and cleanup: Planning, preparing, and serving well-balanced, nutritional meals, and cleaning up food and utensils after meals.
¦ Safety procedures and emergency responses: Knowing and performing preventive procedures to maintain a safe environment as well as recognizing sudden, unexpected hazardous situations and initiating emergency action to reduce the threat to health and safety.
Fitness
Hobbies
Relationship
Sexuality
Holidays
Entertaining
Friendships
Sleep
Worship
Source: Distributed by Nancy Mitchell, Mitchell Disability Assessments and Life Care Planning, Apple Valley, MN. Reprinted with permission.
The educational requirements for the OT have expanded over time. Previously, a registered occupational therapist (OTR) needed a bachelor’s degree to enter practice, and working therapists with that level of education continue to practice. However, the current requirement of a beginning OT is a master’s degree. There has been a more recent movement for OT to obtain a DOT (doctor of occupational therapy) as an entry level of practice. This is a clinical doctorate with an emphasis on enhanced clinical practice. Some experienced therapists are expanding their credentials with this additional education. Certified occupational therapy assistants (COTAs) typically have an associate’s degree. OT practitioners are licensed by their individual states.
The OT that treats the person for whom the life care plan is being written is certainly the best first contact for obtaining OT recommendations for the plan. If that therapist is unwilling or unable to make the needed projections, additional OT evaluations may be needed. For example, an individual with a spinal cord injury may have had excellent OT interventions during his or her acute rehabilitation but the treating therapist may not have the expertise to provide input into the life care plan about needed driving adaptations. An additional evaluation from an OT specializing in this area may be needed.
Like many other medical professions, OTs tend to specialize in areas of practice. These include pediatrics, geriatrics, hand therapy, cardiac rehabilitation, physical disabilities, mental health, ergonomics, and health and wellness programming. While more OTs are becoming life care planners, the forensic arena is fairly new for the field. In general, OTs are not trained in litigation and may be reluctant to provide opinions that will be used in a legal setting. An inquiry to the state OT association may be a helpful first step.
In addition, while OTs pride themselves in addressing the needs of the whole person, their consideration of therapy and equipment needs tends to address the short term rather than the lifelong projections that are needed for a life care plan. As a part of therapist training, long-term goals that are a part of the typical therapy plan address needs in a given episode of care, which may mean areas of focus in the weeks or months ahead rather than over a client’s entire lifetime. A pediatric therapist treating a child with cerebral palsy, for example, could be encouraged to project therapy and equipment needs throughout childhood and adolescence, but lack the experience or expertise to know what this child will need in his or her adult years. That being said, there are numerous components of the life care plan within the direct expertise of the OT.
OTs are unique in the roles they offer as the health care professional on the team with the knowledge and treatment of allowing people as much independence as possible in their daily lives. Their opinions can include that a person will need the assistance of a caregiver to complete daily activities or for safety and supervision in the home/school/work setting, or the use of equipment for safety or energy conservation. The next section describes many of the sections of a life care plan that could be enhanced with the input of an OT.
In general, costs of an OT evaluation can vary greatly. Medical Fees in the United States (PMIC, 2008) reports that the charge for an OT evaluation is $124 (50th percent) to $190 (90th percent), without geographic modifiers. However, in this author’s experience it is not unusual for an OT evaluation at a facility-based practice to be in excess of $400. OTs have direct access in many states to evaluate a person without a doctor’s prescription. However, health care facilities require a doctor’s order for an OT evaluation as this is needed for payment by insurance providers.
The OT should be comfortable providing recommendations for ongoing OT evaluations. However, the therapist may be unwilling or unable to project lifelong needs as this is outside of the typical frame of reference for a given therapy episode of care. In this case, the life care planner can defer to the opinions of the physiatrist who will likely be more comfortable providing projections for lifelong needs. It is typical for the author to include an annual OT evaluation for people with lifelong disabilities such as spinal cord injury, cerebral palsy, or upper extremity amputation.
Of special note for pediatric clients is the Individuals with Disabilities Education Act (IDEA), reenacted in 2004. The IDEA is a federal law ensuring services to children with disabilities who attend public schools throughout the nation. The IDEA governs how states and public agencies provide early intervention, special education, and related services to more than 6.5 million eligible infants, toddlers, children, and youth with disabilities (retrieved June 28, 2008, from http://idea. ed.gov). As part of the law, the IDEA is mandated to provide OT and other therapeutic services that are educationally related to children ages 3 to 21 who attend a public school. The implication for the life care planner developing a life care plan for a child covered under the IDEA is that, for example, a child with a brain injury may have OT evaluation and treatment services written into her individualized education program (IEP) as it relates to their education needs and as provided for by the school system; however, it is important for the life care planner to consider the child’s needs outside the school setting as well. In the author’s opinion, it would be unusual for a child who qualifies for school OT not to need additional OT services external to the school setting.
The OT should be comfortable providing recommendations for ongoing OT treatment. However, similar to the previous discussion, the therapist may be unwilling or unable to project lifelong needs as this is outside of the typical frame of reference for a given therapy episode of care. Again, input from the treating physician is likely to be invaluable.
The OT is an expert in daily living activities. The OT should be very helpful in providing specific suggestions of equipment needed to enhance the client’s independence and/or to facilitate the caregiver’s task of providing care for the client. This will allow a life care planner to include specific items in the life care plan that will be of benefit to the client. In this author’s opinion, rather than providing a general allowance for these items, a method often seen in life care plans that probably have not utilized the services of an OT, specific pieces of equipment and replacement schedules, in most instances, can be recommended. This enhances the credibility of the life care plan. However, it is recognized that itemizing numerous low-cost items, such as each adapted eating utensil, plate, and cup, can be unnecessarily detailed. The OT could also be helpful in projecting equipment that, while perhaps not needed currently, will address aging-related factors and enhance abilities as a person ages.
Many OTs perform wheelchair and seating evaluations as a part of their practice. The OT’s input into current and future needs for wheelchairs are likely to be very helpful to the life care planner. The OT who performs these evaluations will be able to make projections about the changing need
for wheelchairs over time such as a child’s ability to benefit from powered mobility or a person’s future need to move to a power-assisted wheelchair.
The OT is often involved in choosing appropriate cushions, wheelchair backs, carrying bags, cup holders, and other accessories. Their input into this portion of the life care plan could be invaluable.
The qualified OT is an expert on bath, toileting, and transferring equipment. They may also have significant knowledge of bed, transportation, and ambulation aides.
OTs commonly make splints for the arms, wrists, and hands. They have knowledge about the type of splint that is needed and the frequency of replacement. Many OTs also work with upper extremity amputees in their clinical practice. Prosthetists, however, are likely to have a greater depth of knowledge about prosthetic options, costs, and replacement frequencies.
OTs will vary in their expertise in this area. Most should have a working knowledge of crutches, canes, walkers, standers, gait trainers, and positioning equipment. Physical therapists are more likely the experts with regard to this equipment.
OTs have basic education in accessibility needs for people with disabilities. Some have additional training and may be experts on ergonomics and home modifications. It may be very helpful to obtain an evaluation of a home access specialist to provide the detail needed to get more exact costs and recommendations. This would need to be discussed with the retaining attorney as there will be a cost for this evaluation. Few OTs have this credential.
Supplies in the life care plan that relate to adaptive clothing and adaptive feeding generally fall under the expertise of the OT. See also the previous discussion on ADLs.
An OT evaluation may be a critical determination of the amount of care and supervision that is needed for a given individual. OTs are trained to evaluate safety and the ability to perform ADLs and IADLs. An OT can also determine when it is important to provide assistance because of limitations due to pain or impaired endurance as well as age-related factors.
Many OTs are experts in computer use and adaptations that are needed to access the computer.
OTs often evaluate and suggest home exercise programs and equipment needed to maintain strength and endurance. They can also be a resource to identify camps or special recreation programs or activities for individuals with specific disabilities.
Some OTs have a Driver Rehabilitation Specialist certification and perform driving evaluations and adapted drivers’ training as part of their clinical practice (see www.driver-ed .org). They can provide invaluable input into the need for driving evaluations and adaptations, costs, and replacement schedules for this equipment.
OTs may be helpful in determining how a given complication may affect functional abilities and the need for equipment in the future. OTs also have knowledge of the risk of overuse injuries for people with disabilities.
Some OTs specialize in ergonomics and worksite accommodations. They can provide valuable input about injury and overuse prevention and offer suggestions for equipment to enhance success in the workplace.
As seen in the preceding section, many of the core components of a life care plan fall under the professional domain of the OT. An evaluation from an OT may be key in making life care plan recommendations. That being said, it will likely be important to communicate to the therapist what information is needed prior to the evaluation. Additionally, an evaluation in the home and, separately, the community may be particularly helpful. The case study at the end of this postr will illustrate the value of the OT assessment in the formulation of a life care plan.
This author (Mitchell, 2004) reported that aging-related complications such as pain, fatigue, decreased strength and endurance, and subsequent loss of functional abilities occurs 20 to 30 years sooner for people with early in life onset disabilities than for their able-bodied peers. This can have significant impacts in the life care plan both for care and equipment. In general, the need for care will increase as functional abilities decline. Changes in equipment and assistive technology are likely to be needed as a person is less able to function in his or her daily routine, and it is important for the life care planner to anticipate and plan for these changes.
Needs related to aging can vary by disability type. Mitchell (2004) provided the following recommendations to consider when developing a life care plan for individuals who have cerebral palsy, spinal cord injury, or amputation.
Summary of implications for the life care plan for a person with cerebral palsy (Mitchell, 2004, pp. 96-97):
¦ Case management is an important consideration for the person with cerebral palsy. It may be difficult to find or access specialized care. The necessary time and equipment needed for regular preventative care may not be readily available and case management assistance may be critical even for those people with normal cognition.
¦ Specialized dentistry may be needed lifelong. Special equipment for oral care may be needed.
¦ Consultation with a dietician at regular intervals will be helpful in problems associated with weight management (over- and underweight), which is common in this disability group.
¦ Alternative means of mobility should be an early consideration for those with any ambulation impairment. Powered mobility is an important consideration for distance mobility.
¦ A lifelong fitness routine is critical in maintaining strength, flexibility, endurance, and independence. A physical trainer may not have the needed expertise to meet the specialized needs of this population. Physical or OT evaluations every 2 to 3 years over a lifetime may be a more appropriate choice.
¦ Consider increased care needs as the person ages.
¦ Assistive technology needs can change over time (e.g., a normal bed may work well in youth but a bed cane or hospital bed may be needed in later decades).
¦ An ergonomically correct environment in both the home and work setting is critical in preventing injury. Ergonomic assessments at life phase changes may be appropriate.
¦ Pain management, while not needed in childhood, may well become important as a person ages.
¦ Periodic psychology assessments may be helpful in monitoring psychological status.
¦ Potential aging-related complications such as overuse syndrome and potential for falls should be addressed.
Summary of the implications for the life care plan for a person with spinal cord injury are as follows (Mitchell, 2004, p. 99):
¦ Periodic assessments with a dietician may be important for weight control.
¦ Powered mobility should be considered for those needing to travel long distances or on uneven ground (e.g., college campus or rural environment) even with manual wheeling proficiency. Manual assist wheelchairs should typically be introduced 10 to 15 years after injury and powered wheelchairs for spinal cord injured clients using wheelchairs 20 years after injury.
¦ Other assistive technology needs are likely to change over time. Occupational and physical therapy evaluations to assess assistive technology are recommended.
¦ An ergonomically correct environment in the home and worksite will minimize injury risk. Period ergonomic assessments at life phase changes may be indicated.
¦ A lifelong fitness routine is critical in maintaining strength, flexibility, endurance, and independence. A physical trainer may not have the needed expertise to meet the specialized
needs of this population. Physical or OT evaluations every 2 to 3 years over a lifetime may well be a more appropriate choice.
¦ The life care plan should address the potential need for increased care as the person ages and consider the possible psychological impact of increased dependency.
A summary of the implications for the life care plan for a person with amputation is as follows (Mitchell, 2004, p. 100):
¦ An ergonomically correct environment in the home and worksite will minimize injury risk. Ergonomic assessments at life phase changes may be helpful.
¦ Weight control is important for prosthetic fit and to help from overstressing joints. Periodic assessments with a dietician for those with a potential for weight control difficulties is recommended.
¦ A fitness program is essential to minimize injuries related to overuse. Input from therapists or a personal trainer may be a benefit to this disability group.
¦ Alternative mobility may be needed for those with lower-extremity amputations. Age and mobility environment will need to be considered.
¦ Pain management may not be a concern early in the disability for the person with amputation. However, it can become a problem as the person ages.
In review of therapy records, a life care planner may have difficulty deciphering abbreviations used by OTs. While there is a national effort to standardize abbreviations, some may be unique to therapists and some may even be specific to a given organization. Following is a list of abbreviations that may be found in OT medical records:
AAC Augmentative and alternative communication
AAROM Active assistive range of motion (person needs assistance to complete the full range of motion)
AD Alzheimer’s disease
ADD Attention deficit disorder (now replaced by AD/HD)
ADHD Attention deficit hyperactivity disorder
ADLs Activities of daily living
A/E Above elbow
APD Auditory processing disorder
AROM Active range of motion (person is able to move through the range of motion but may not be able to do so with resistance)
AS Asperger’s syndrome (part of the autism spectrum)
ASD Autism spectrum disorder
AT Assistive technology
B/E Below elbow
B/K Below knee
BMP Behavior management plan
CD Conduct disorder
CGA Contact guard assist (direct contact with the person for safety but no physical assistance)
Certified occupational therapy assistant (typically an associate degree education) Development coordination disorder (DSM-IV 315.4)
Developmentally delayed
Functional Neuromuscular Electrical Stimulation (also see TES & TENS) Instrumental activities of daily living (activities of daily living beyond self-care such as money management, meal preparation, child or pet care, telephone or computer use, use of public transportation, driving, and home cleaning and maintenance tasks) Long-term goal
Occupational therapist or occupational therapy
Occupational therapist licensed (occupational therapists are registered nationally but licensed by the individual states)
Personal care attendant
Picture exchange communication system
Physical therapist or physical therapy
Standby assistance (no direct contact with the person)
Sensory integration
Sensory integrative (or integration) disorder/dysfunction Speech language pathologist Short-term goal
Transcutaneous electrical nerve stimulation
Treatment
Verbal cue
Within functional limits (able to move within the limits needed to perform daily activities but may not have full range of motion or normal strength)
A life care planner was asked to evaluate Jane, a 46-year-old woman who was diagnosed with a T7 spinal cord injury resulting in complete paraplegia. The life care planner visited Jane in her rural home. She had completed her in-patient rehabilitation over 2 years ago. The life care planner was concerned because Jane was significantly overweight and complained of severe shoulder pain. Jane was resistant to going into the city for physiatry follow-up and had purchased much of her durable medical equipment over the Internet. Jane was struggling to perform her activities of daily living and relying more and more on her family for assistance. It was clear that some of Jane’s equipment was no longer appropriate for her needs. Jane did agree to have an OT assessment in her home. And the life care planner found a qualified OT to conduct the evaluation.
An OT with spinal cord injury and home accessibility expertise evaluated Jane. Numerous issues that would have relevance to the life care plan were discovered by the OT and needed items were added to the preliminary life care plan:
¦ Not only had transfers become difficult for Jane; they were in fact unsafe. The OT recommended physical therapy intervention after a physiatry or orthopedic consultation to determine if Jane’s shoulder pain and consequent strength deficits could be improved. If possible, transfer training would need to be retaught. There was an immediate need for a lift. Physical therapy and later PT or personal care attendant hours needed to be increased to eliminate Jane’s need to continue unsafe transfers. See the example life care plan entries in the
following. (Note: In an actual life care plan, items would be distributed into the appropriate categories. For purposes of this post, recommendations have been grouped together and numerous other items not specifically relevant to this post have been excluded.)
¦ A power wheelchair with an elevating seat was recommended. Jane could access her kitchen cupboards, microwave, and refrigerator with an elevating seat. Without it, the OT noted she used poor ergonomics and put further stress on her shoulders. Powered mobility was recommended sooner than what is typical in Jane’s case because of her pain and mobility in her home. Typically, a power assist wheelchair is introduced 10 to 15 years after a spinal cord injury and a power chair 20 years after injury for the manual chair user (Mitchell, 2004). See the following example of a life care plan entry:
Invacare Formula CG Tilt/Elevate for TDX SP baseA power chair with elevating seat is to fully access kitchen and enhance independence. This chair will need tilt-in-space feature because of inability to perform weight shifts secondary to shoulder pain.Source: Lisa Michaels COTA/L, ATS, CRTS, Handi Medical Supply, St. Paul, MN, 2008.¦ A power wheelchair would necessitate a van with a lift. Jane had been going into the community less and less because of her transferring inabilities.
2008 Chrysler Town & Country Touring Van with Braun Entervan ConversionThis van will allow independence in community mobility.$49,960 (less the cost of an average vehicle in the United States in 2007)Source: HDS Specialty Vehicles, www.hdsmn .com.¦ A van with a lift necessitates an oversized garage stall to provide needed maneuvering space for the van, the drop-down lift, and needed clear floor space to roll off the lift and maneuver toward the entrance door. This requires an additional 7 to 9 feet of clear width in one vehicle parking area. Jane has an attached single car garage. It is important to maintain an attached garage for the van so Jane does not have to maneuver through extreme weather elements to reach her van (e.g., snow, rain, ice, etc.) and to acknowledge Jane’s inability to scrape frost off of windows or to remove snow off the vehicle.
1x or may be needed again with additional movesTo allow parking in garage and allow adequate floor space for exit/entry with van lift.Source: Jane Hampton CID, CAPS, Accessibility Design, Inc., Minneapolis, MN, 2008.¦ The OT offered Jane and her family suggestions about rearranging the kitchen, bedroom, and bathroom to improve access and ergonomics. Some OTs have this expertise but the advice of a home access specialist can also be critical in a life care plan. Although there are several areas in the house to consider, such as vertical access, garage overhead door, access into house, doorways, bathroom, kitchen, hallways, floor surfaces, controls, and so on, for the purpose of this post, the kitchen will be addressed to suggest the level of detail and costs appreciated.
¦ The kitchen did not provide any features to assist Jane in independent or safe meal preparation. The original kitchen layout had not been modified to accommodate needed clear floor space for Jane’s wheelchair or to accommodate the need to approach work areas in a forward approach to get close to the task area. Jane has been relying on her family for most meal preparation and cleanup. See the following example life care plan entry for details:
1x (more often may be needed with moves)Rearrange cabinet configuration to provide turning space for the wheelchair and approach to each work area.Replace cabinets with new cabinets. Ergonomically, this will be much easier for Jane to use from a seated position.Provide clear knee space at the sink, cooktop, and one mix/work area and incorporate dual pull-out cutting boards. Replace the kitchen sink with a shallower sink to maximize knee clearance height; drains are to be located at the back of the sink to maximize knee clearance depth.Conceal or wrap drainpipes to avoid hot water burns to Jane’s knees.Install single-lever faucet hardware at the sink.Extend the wall cabinet over the dishwasher down to the countertop so dish storage is located within reach range.Replace the gas range with an electric cooktop that offers front controls.Rewire the range fan and light switch located within accessible reach range.Provide a wall-mounted oven with a side- swinging door.Provide a pull-out board below or adjacent to the oven to rest cool items removed from the oven. Incorporate pull-out shelves in base cabinets.Incorporate a pantry, with pull-out shelves.Replace the existing refrigerator with a side-by- side refrigerator that has water and ice in the door, allowing storage for both compartments in reach range.Relocate outlets and switches to the front face of countertops. Provide task lighting at each work area. Replace the kitchen flooring to accommodate newly configured cabinetry and to extend the flooring into each knee space. Ensure the transition to adjacent floor materials is neutral.Source: Jane Hampton CID, CAPS, Accessibility Design, Inc., Minneapolis, MN, 2008.¦ A tub lift was recommended. While Jane had a shower chair, her spasticity and relaxation were improved with warm water. Jane could not get in the tub without a lift. See the following example of a life care plan entry:
Aqua Tec Beluga RSB with reclining lateral support, wedge cushion, and rotary seatAllow for safety and enhanced independence with tub baths.Source: Lisa Michaels COTA/L, ATS, CRTS, Handi Medical Supply, St. Paul, MN, 2008.¦ Jane’s current wheelchair cushion needed replacement. See the following example of a life care plan entry:
Infinity Lo Contour FloGel CushionProvide pressure relief, comfort, and positioning.Source: Lisa Michaels COTA/L, ATS, CRTS, Handi Medical Supply, St. Paul, MN, 2008.¦ Jane was educated about shoulder overuse in people with spinal cord injury. Fitness equipment that could be used without harm was suggested. See the following example of a life care plan entry:
Replacement/ServiceFrequency
Upper body strengthening from wheelchair.Exercise bands to be used as an alternative to Bowflex or for out of home use.Regular assessment from a personal trainer will be needed to advise re: exercise/strengthening program as medical status changes and with aging. It is possible to get this same advice from a PT but cost is likely to be greater unless accomplished during annual PT evaluation.a It is possible that a physical trainer/PT may recommend alternative equipment.¦ Jane was only 46 years old, 2 years after her injury, and already experiencing shoulder pain. The OT recommended an item, while not currently needed, to be added to the life care plan as Jane aged:
This device will assist with bed mobility/ transfers. While not currently needed, it should be added to the plan beginning at age 55.Recommendations from the OT may be vital in the development of a life care plan as many components fall under the expertise of the OT. However, the life care planner should remain aware that OTs typically think about a current episode of care and may be unaccustomed to projecting lifelong needs. Additionally, few have forensic experience and may be reluctant to offer an opinion that may be used in a legal setting if they are not experienced or familiar with litigation issues. They may need education about how the information will be used and what it will mean for them to offer an opinion for the life care plan. Therapists also tend to specialize in specific areas of practice and consultation, and more than one OT may be needed for a specific life care plan. Consultation with OTs who specialize in other professional practice areas can bring added depth and detail to the life care plan.
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