The Role of the Physical Therapist in Life Care Planning

Physical therapists serve as facilitators of health. They treat patients with a broad range of potential participation from other professionals, family, and friends. An open mind-set to any given patient and situation is crucial to the enhancement and facilitation of health. The treatment of signs and symptoms, pain, irritation, lesions, catastrophic injury, and dysfunction are given viable solutions from the unique perspective of balanced deliverance of effective physical therapy skills. This cre­ates a synergistic application of physical therapy with the patient’s willingness to be responsible toward maximizing health and function.

Cooperation with all professionals, financial supporters, family members, and friends contributes to the overall facilitation of health. Insight to innovative and new techniques as applied to a specific patient’s needs is an opportunity to promote physical therapy skills with positive participation by the patient. It is vitally important that the well-being of each patient be considered in long-term and short-term care.

In dealing with life care issues, there are fundamental questions and paradigms of thinking to be asked of the physical therapist and others involved in the care of the patient or client, such as the following:

¦     What was the level of health, function, and lifestyle before the injury, disease, lesion, or dysfunction?

¦     What level of health, function, and lifestyle can be achieved given the present status of the patient and his or her physiological, social, psychological, financial, and spiritual environment?

¦     What are the ideal, hopeful goals and plans, balanced with the real goals and plans?

¦     What are the integrated thoughts on parameters and boundaries of the patient’s thinking in relationship to the process of healing and health?

The physical therapist and all persons involved in life care planning should integrate their plans with the following concepts being interwoven in their health care delivery process:

¦     “Seek first to understand, before you are understood.” (Covey, 1989, p. 239)

¦     “Walk a mile in my shoes.” (Song performed by Joe South)

¦     “Do unto others as you would have them do unto you.” (Matthew 22:39 paraphrased, KJV)

¦     “Understand the patient’s languages of love—care and receiving”. (Chapman, 1995)

As we examine life care goals and priorities for the patient, we are building a foundation of true principles to develop our skilled delivery of physical therapy. Therefore, we return the patient, as much as possible, to full health and function with basic human dignity, rights, and privileges. If
full health and function are not attainable, then at the very least we should create a plan, delivery, and environment of highest quality and dignity of life, minimizing suffering and creating a door of hope for tomorrow. This also allows us to participate in one of the greater values of life, the opportunity for fellowship and to relate to a person’s unique experience of life, a form of shared enlightenment.

Again, the attitude for delivery is based on how we would want to be treated in any given situation. This attitude counteracts selfish goals and stirs physical therapists to strive for the best scenario and outcome, for the goal is quality of life. This way of life care planning requires com­mitment to the process. It includes active responsibility and participation of both the physical therapist and the patient.

The physical therapist has the unique capability of providing a large spectrum of evaluative techniques as well as evaluative protocol. The evaluation process is a multilevel course of action. Full detailed evaluation processes can occur on various levels or may be specific parameters, as well as being appropriate to special situations.

In the general areas of medical studies and patient situations, a physical therapist is presented with a variety of evaluative techniques. These include the areas of orthopedics, neurology, soft tissue dysfunction, wound care, sports medicine, hand therapy, industrial medicine, and cata­strophic injury to specific or multiple areas. The physical therapist can also specify evaluative techniques by age groups, including pediatric, youth, adult, and geriatric populations. Besides the areas of physical dysfunction and areas of given diagnostic diseases, lesions, or injury, a compara­tive evaluation and preparation for return to life evaluations can be delivered. Evaluations that involve return to life skills, including activities of daily living (ADL), function, work-related skills, ergonomic analysis, sports-related skills, and overall total life skills can be offered with the appro­priate parameters in order to be specific or holistic in nature.

The evaluation process involves consideration of the adaptability of the patient and the circum­stances in which the patient is placed. Evaluations can involve specific areas of spine, extremities, and body systems, as well as specific areas of dysfunction and injury. General areas of consider­ation and evaluation involve the following.

Review the existing medical history and subjective information.Interview the patient. This involves a general subjective overview, including verbal con­tributions from the patient, type of injury, surgical history, disease process, and dysfunc­tion. Other areas involved in subjective information include present job situation, activity level before and after injury, previous types of physical therapy received, and medical care received.Consider psychosocial questions and interview as they relate to the present dysfunction. Other professionals may have covered psychosocial issues, but it is always appropriate to establish a baseline of understanding of other involved issues in the patient’s dysfunction.As appropriate, communicate with family and friends about observed subjective and objec­tive information.

The subjective information and input obtained from the client are established as the baseline for other evaluation considerations. Pain evaluations using standardized questionnaires as well as various tests have benefits for cross-correlation and reliability of subjective information. These essential baseline data of pain characteristics assist in leading the therapist toward establishing present dysfunction and potential for further dysfunction and other complicating factors.

General characteristic complaints of pain are to be established, such as:

¦     The location, duration, and frequency of the pain.

¦     The specific qualities of the pain—constant, intermittent, diffused, localized, sharp, numb, burning, dull, tingling, radiating, quick, or sustained.

¦     Examples of specific pain (e.g., night pain, pain upon arising in the morning, pain with activity, or pain throughout the day).

¦     Clarifying the pain intensity by using a scale—0 being no pain and 10 being acute pain.

¦     Examples of activities that increase pain and activities that decrease pain (e.g., sitting, stand­ing, walking, lying, bending, massage, ice, or heat).

¦     Is the pain getting better, getting worse, or remaining the same?

¦     What is the maximum length of time the patient can perform any particular function, such as sitting, standing, walking, and driving?

Pain questionnaires should also reveal relationships between how much function the patient can perform and at what level the pain occurs, such as how much can the patient lift and carry? What provides relief? What positions and body ergonomics or equipment assist in decreasing pain and promoting function? Pain drawings and various standard pain scales are other informative tools to be utilized for comparative information, with coordination of other data.

Past medical history and personal information also are important to understanding the direc­tion of evaluation, treatment, and plans for function and health care. The new standards and parameters established under the Health Insurance Portability and Accountability Act (HIPAA) have to be considered in all aspects of care and planning.

Referral questions such as return to work, work duty load, time load, consistency testing, and impairment ratings are also directional in the evaluative and care process.

An objective evaluation will analyze basic functional activities, such as the patient’s gait; sitting, standing, and rolling activities; and appropriate supportive devices.

Observation of the basic structure of the anatomy, weight-bearing capabilities, and appropriate body landmarks is an essential part of this examination. One should note appropriate posture, compared to the correct anatomical position, and specific noted deviations. Considerations for historical body habits, adaptive shortening, and contractures are important data. Also note the self-limiting or compensated functions and adaptations the patient has made. These can occur voluntarily or involuntarily.

Other observations should include:

¦     Basic soft tissue evaluation

¦    Appropriate understanding of joint position

¦     Intervertebral movement

¦     Normal joint movement

¦     Range of motion (ROM), including cardinal and diagonal planes

¦     Gait analysis

¦     Flexibility

¦     Manual muscle testing

¦     Strength testing with technologies and instruments

¦     Functional test

¦     Sensory tests

¦     Special tests

Special tests can target specific examination of any given extremity or body part. These tests rule out various complications and evaluate appropriate function and dysfunction.

Other appropriate evaluations include:

¦     A neurological exam would include basic reflexes as well as appropriate strength measuring, with manual muscle testing and sensory examination. It should be noted that during the evaluation any cross-correlation with a basic generalized assessment can be made with more specific evaluations, including functional aspects of a work capacity assessment (WCA), functional capacity assessment (FCA), and isokinetic, neurological, and balance testing and sensation tests.

¦    Joint mobility evaluations include the normal ROM, correct anatomical position, appropriate accessory movements, and physiological movements.

¦     Soft tissue evaluations include palpation of tissue, noting restrictions, trigger points, pliabil­ity, and plastic and elastic responsiveness. The evaluation of soft tissue and tender points should include restrictive qualities and tenderness nature and the response of the tissue (Jones et al., 1995). The evaluation of articular structures should include pain, irritation, and inflammation status as well as movement patterns being evaluated. The functioning of soft tissue and joint structures as a synergistic pattern should be noted. Functioning activities such as sit to supine and return, rolling to supine, side lying and return, and overhead reach are part of the evaluation. The evaluation of functional positions and assuming positions, including the quality of movement as well as any centralization or peripheralization of pain, signs, and symptoms should be considered in this process.

¦     Other palpation skills include evaluating muscle play, restriction, guarding, reflex contractions, soft tissue restrictions, trigger point, and referred pain. Intervertebral movement evaluation is based on a numerical scale set between 0 and 6, with 0 being ankylosed and 6 being unstable; 3/6 is normal. The intervertebral movement can also be classified as hypomobile, hypermobile, and painful. The general evaluation can be broad or specific.

The terms work capacity assessment and functional capacity assessment are sometimes used synonymously (Polinsky, 1983; Blankenship, 1989). They can also be more definitive, with WCA being an evaluation used for baseline of work capacities. The FCA would involve a more direct study of basic, functional activities of daily living, with the potential of also evaluating work-related activities. The WCA/FCA can be done at the beginning, middle, or end of any
treatment evaluation process, or as part of a total perspective of life care planning depending on what is needed. There can also be varying degrees of specific details in the WCA, since the parameters are determined by the physical therapist’s understanding of the goals of the evaluation process. The WCA/FCA can occur during the initial stages of the life care planning process or can be extended throughout the span of the life care plan. Follow-up assessments are to upgrade and adjust the goals and plans for the patient, as well as to update the baseline data for reevaluation. All physical therapy evaluations are done in coordination with other professionals and their evaluations. Integrating the results of other health professionals’ assessments into the physical therapy plan allows for a more holistic approach in achieving the goals for the individual patient.

There are a number of evaluative techniques in the areas of WCA and FCA that are effective and appropriate for any given situation in the life care planning process. According to Blankenship (1989, p. 122), “the WCA or the FCA is an evaluation of physical capabilities and limitations as they relate to work, recreation, and ADL. It describes the optimum and maximal capabilities in terms of strength, endurance, related joint problems, fine and gross motor coordination, limiting factors and methods of functional and task performance.” Therefore, in order to make a more accurate assessment, the WCA/FCA should involve measurements of different activities.

General areas tested in basic functioning include:

¦     Lifting, which includes level lift, floor to table, and carrying

¦     Pushing to maximum tolerance

¦     Pulling to maximum tolerance

¦     Standing, sitting, and kneeling tolerance

¦     Bending, stooping, and squatting

¦    Walking, climbing, and balance

¦    Coordination activities, including the upper and lower extremities with gait analysis and gait function

¦     Pivots, forward reach, overhead reach, etc.

The evaluation often requires an assessment of time and repetitive parameters specifically defined as not required, occasional (up to one-third of the time), frequent (one-third up to two- thirds of the time), and constant (over two-thirds).

These tests can take on specific work or functional aspects. Various lifting tests have been developed to improve consistency, reliability, validity, and standardization of data to be applied to evaluation and supportive conclusions, results, and directions of rehabilitation.

Isometric lift test, strength test with one repetition, repetitive loads, dynamic and static, grip test, and other integrated techniques utilizing new technologies, programs, and standardized tech­niques and databases are part of the evaluative tools available. These tests are also cross-correlated often to arrive at reliability, validity, and consistency of effort parameters. Many tests, for example, EPIC (Employment Potential Improvement Corporation, developed by Matheson, available at www.epicrehab .com), have criteria and standards for application, databasing, and analysis.

Establishment of proper body ergonomics and posture during functional ADL, as well as work- related activities, is important not only in establishing and facilitating present health, but also in preventing further dysfunction and injury. It is important that ergonomics be applied in the evaluation process as a tool to determine the patient’s capabilities (physically and mentally) in comprehending the issues of proper body mechanics. In the evaluative functional capacity/work capacity arena, proper ergonomics and posture will need modifications based on equipment handling capabilities and the use of adaptive equipment.

Functional aspects of ADL, such as personal grooming, hygiene, and dressing, are issues that are often considered in the FCA (also see this post on the occupational therapist’s role). Areas of nutrition and speech can also be evaluated by a qualified physical therapist with appropriate training. Some aspects of the FCA, as well as other aspects of WCA, are often overlapped in the expertise area with the occupational therapist, speech therapist, recreational therapist, ergonomic specialist, and appropriate physician specialist. In any evaluative process, standard body mechanics are to be evaluated by the therapist during the lifting task portion, as well as basic functional activities task, in order to ensure the most advantageous body mechanics for handling basic ADL functions and work functions.

Evaluation for sports and other specific recreational skills needs to be considered in the evaluative process. There is a correlation between functional skills, work skills, and sports or recreation skills. Collating these concepts provides for efficiency of movement, as well as promoting correct body function and health, within the parameters of the given dynamics of the patient’s physical challenges.

Evaluation of body mechanics is crucial to determine potential for wear and tear on the patient. Appropriate alternatives, suggestions, and varying procedures and skills for handling any given dysfunction should be understood. Full comprehension of these procedures and skills will enhance the development of proper use of strength, as well as minimize irritation and pain. Also, with proper evaluation of the patient’s present knowledge and skill, the need for further training or education can be developed. The role of the physical therapist from the basic evaluative process or WCA/FCA can essentially be refined or specified for any catastrophic impairment.

When performing the evaluative process and listing objective findings, substantial data are important to assist the delivery of health care to the patient. Gathering of data and information in the objective format also plays an important role in defending the patient’s present situation and in presenting the plan for future services. Skilled assessment is vital in giving direction for the best possible outcome for the patient’s return to health, as well as providing long-term care. It is appropriate to develop parameters allowing for changes in the patient’s function and health and in the patient’s environmental situation and basic home lifestyle. Adaptability and changes in preparing the patient for return to work or work activities are crucial in understanding the format for performing the evaluative FCA or WCA.

Isokinetic testing provides a technologically advanced approach to human performance testing, rehabilitation, and exercise. The test allows all major joints of the body, including the upper extremities, lower extremities, and trunk, to be evaluated and compared. Bilateral testing, as well as comparative testing, can differentiate between muscle groups in the isokinetic test. Isokinetic exercise is performed at a constant speed throughout the range of motion. As the muscle applies
force, it is resisted by appropriate proportional opposing force. Therefore, the speed of movement is kept constant. The isokinetic evaluation process or exercise provides an excellent means of qualifying many aspects of movement and function, including muscle torque, work, fatigue, ROM, and peak torque levels. As the sophistication of technology improves, more accurate and appropriate measuring devices will allow for basic data and parameters in which to assess body function. The isokinetic test can also be used in a cross-correlation with functional measurements being taken, as well as manual muscle testing and basic lifting capabilities. This cross-correlation can help define the patient’s present level of activity and assist in determining symptom magnification and inappropriate illness behavior parameters.

As in the general evaluation given earlier, the neurological examination can be an expanded appraisal involving specific parameters. It involves specific emphasis on neurological and neu­romuscular mechanisms of the body, including muscle test and evaluations, sensory tests, functional and neuromuscular developmental sequencing and evaluations, and specific injury evaluations to the central nervous system or peripheral nervous system. Associated dysfunction as in gait, transfers, dressing, grooming, hygiene, sports, and work can also be neurologically evaluated.

Cardiovascular fitness evaluations incorporate a range of specifically applied stress testing under the supervision of the physician and appropriate professionals, including a physical therapist. The cardiovascular appraisal is often involved in the FCA/WCA, which establishes a minimal level of conditioning protocol that could include treadmill, bicycle ergometer, or step-climbing evalua­tions. All these tests have basic guideline parameters. Often a cardiovascular clearance evaluation is needed before other evaluations, WCA, and FCA can be performed. The pertinent physician or professional may give appropriate parameters under which the cardiovascular system may be stressed or tested.

The neuromuscular skeletal function is evaluated in specific areas or systems and holistic body systems and functions. This evaluation can involve the study of the balance system of the body in relationship to gait and functional activities. Proper consideration for a proprioceptive feedback system in static and dynamic functional activities is measured. This evaluation can involve specific job activities, sports activities, and ADL, with coordination, balance, and skill being integrated into foundation data. The criteria involve general standardized tests, as well as specific tests designed by the physical therapist to the given situation based on age, developmental sequencing, and specific goals of the functional or life care demands.

Gait evaluation involves specific or general evaluations of the patient’s ambulatory status in a variety of environment situations. Consideration for adaptive equipment, tools, and prosthetics is part of this evaluative process.

Return to work and physical demand categories as published by the Department of Labor, in combination with consistency of performance, positional tolerances, and lifting tests and other evaluative procedures, create a viable tool to have a “systematic process of measuring and develop­ing an individual’s ability to perform meaningful tasks on a safe and dependable basis” (Hanoun Medical, 2002).

The role of the physical therapist as a facilitator in health care is to treat, train, condition, and assist in the direct structure and setting of goals for the patient. Basic communication to the patient, family, professionals, and financial parties serves as a primary directive of achieving the life care planning process. It should be understood from the physical therapist’s point of view that his or her establishment of feedback into the life care planning process is crucial in developing a long­term solution for the patient’s care. Proper structured treatment, evaluation, follow-up physical therapy, and training involve clear communications among the professionals involved so that all forms of facilitation to functioning are utilized.

An attitude of openness and understanding should be the goal while preparing the patient for the highest level of independence. This same directive should be applied when providing options for those who will need long-term or lifelong physical therapy. Examples of this attitude and structure are as follows: a patient who is in need of a wheelchair and is dependent upon the wheelchair for most of her life will develop other dysfunctions. Typically there is greater wear and tear on the upper extremities, cervical, neck, thoracic, and spine, due to having to handle a greater load of total body function in the upper extremities and upper trunk and neck areas. It is important to understand that lower extremities that are not functioning do not provide support and therefore cannot be used in functional skills. This greater demand of activity and function is placed on the remaining working cardiovascular, neuromuscular, and skeletal systems. These patients or clients are susceptible to greater breakdown of all involved systems and structures. Effective planning involves addressing the immediate dysfunction in preparing the patient to develop a higher level of independence and future preparation. It should also be understood that the patient would in all probability have an increased ratio of wear-and-tear factors and greater susceptibility to further lesions and insult in his remaining systems and structures.

The dysfunctional areas of the body and mind will still need suitable care and support. These would include areas of strength, ROM, hygiene, wound care, tissue function, and basic vascular and neurological functional considerations. Sometimes injured areas become hypersensitive, even though not functional. Phantom and referred pain can occur in the dysfunctional area.

As in any treatment or evaluation process, the therapist should be open-minded and aware of any new studies or opportunities to increase the function and promote the facilitation of health in the injured area. This especially applies for adaptive equipment. The progressive use of equip­ment, awareness of advanced technology, and foresight to predict need are essential. For example, a lower-level tetraplegic patient would commonly require a primary power wheelchair for basic ambulating. However, there are occasions in which an additional manual wheelchair would pro­vide the patient with a variety of sitting postures, backup to the power chair, and an opportunity for the wheelchair to be used as a piece of exercise equipment. The manual wheelchair provides an
excellent source of exercise potential and opportunity for the patient to develop some control and direction in ambulating.

Thoughtful modifications and supplements to the patient and the given situation, with appro­priate equipment, should be considered for both short-term and long-term care. This allows the physical therapist and the life care planning team to develop a full perspective in returning the patient to the highest level of independence and an appropriate, dignified lifestyle. Motivating, encouraging, and challenging the patient to use equipment and supportive devices are part of the evaluative, training, and treatment process.

Financial considerations include original equipment, maintenance, modifications, and replace­ment equipment. All these factors are to be considered over the patient’s life span. As the patient changes and various challenges are presented, considerations for equipment should be appropriate to the life care plan and goals. Financial support for equipment and the evaluative process should be based on the highest goals and principles presented.

In the life care planning process, an evaluation establishes the baseline for treatment through­out the process. In many situations, specific treatment by the physical therapist is required and involves not only therapy, but also ongoing evaluation. Physical therapy treatment may involve eight basic categories:

EducationConditioningPhysical medicine treatmentFunction-specific and ADL-specific treatmentOccupational and industrial physical therapySports physical therapyTotal life relationship skills and integration treatmentBoundaries and communication skills

Education involves an emphasis on ergonomic principles applied to posture and body mechanics, and essential principles for carrying out assisted or independent programs of conditioning, strengthening, ROM, and functional care. Education in ADL, functional, sports, and work- related skills is delivered to all parties involved. It is important that these skills are developed in the patient’s real-world setting and that there is ample opportunity to implement them in an appropriate manner—with supervision, leading toward independence as a baseline goal. The appropriate support of professionals and family members in the real-world setting will require adaptive thinking.

Establishment of specific patient potential in any given area needs to be determined and understood by the patient and team members. An understanding of the patient’s situational life­style, critical work demands, task analysis, functional activities, and recreational plans is impor­tant. The patient’s understanding of educational information presented and the development of a functional delivery by the patient in handling basic nonmaterial ergonomics and essential material ergonomics should be considered. Material handling and nonmaterial handling ergo­nomics are matters not just of work-related issues, but also of functional ADL and the total environment.

Integration into the whole aspect of the patient’s life care with the life care planning team on an as-needed and program-developmental basis will be required. This will probably require the physical therapist to coordinate with the patient/client, other professionals, and family members to follow through with essential concepts of physical therapy education.

Conditioning involves aerobics, cardiovascular, and physiological conditioning. It should be noted that in conditioning, appropriate adaptations to the patient’s/client’s needs will be made and evaluated, as well as developed into a working solution by the physical therapist. Strengthening, which will incorporate specific muscle dynamics, will be used to increase strength levels for performing functional activities, work activities, sports activities, and ADL. Specific areas of strengthening can involve techniques in cardinal and diagonal planes, which can involve singular movements or multidirectional movements. The physical therapist has at his disposal the use of many strengthening techniques, including isometrics, isotonics, isokinetics, plyometrics, and proprioceptive neuromuscular facilitation (PNF). Strengthening could involve rotational, multidirectional facets to prepare the patient for a variety of lifestyle situations. Mobility, stretching, and flexibility categories are used synonymously to describe appropriate mobility exercises to ensure basic principles of full functional ROM in both physiological and accessory patterns. Using balanced concepts of strengthening without strain or further injury is of vital importance in designing a program specific to the individual patient and situation.

The integration of all conditioning factors with functional skills, ADL skills, work skills, and sports skills should be considered and integrated into life care planning. Specific neuromuscular, balance, and coordination activities allow the integration of the central nervous system and the peripheral nervous system to handle ADL, functional, work, and sports activities. Ballistics and dynamics are stresses to be applied to prepare the patient to handle a variety of velocity forces and changes that occur in any lifestyle situation. This can involve specificity of training at various speeds and various levels of physical performance.

Physical medicine treatment includes the use of appropriate medications, modalities, manual therapy, and specific exercises. Physical therapy medicine is used for basic signs and symptoms, which may include pain management, wound care, and improving function. Physical medicine includes the areas of specialized program development or treatment, which could include relaxation techniques, weight control, and appropriate uses of supportive devices, equipment, and braces.

Function-specific and ADL-specific treatment are specific treatment programs the physical therapist can use to encourage increased functional capabilities, such as in gait, transfers, personal hygiene and grooming, speech, and general ADL.

Occupational and industrialphysical therapy involves the process of creating a situation in which a patient/client may progress from a beginning level of handling any job task to the actual per­formance of the job. The job-specific program can involve a program starting in the clinic and being transferred to the on-site job location. Work hardening, work conditioning, and work start are synonymous terms to describe this process.

Sports physical therapy involves the direct relationship of physical therapy in establishing appro­priate conditioning and training, structure, and protocol. This skilled development of parameters and goals creates an atmosphere that develops independent training techniques, as well as inde­pendence to continue higher levels of sport or sports-specific performance.

Total life relationship skills and integration treatment involves the physical therapist working with the patient, family, and total environmental in developing a workable plan structured for assisting the patient in facilitating her full health at the highest level possible. This total life care integration involves a coordination of all previous physical therapy treatments and evaluations with the potential for upgrading, changing, and adapting any given treatment plan and program.

Boundaries and communication skills involve personal and relationship effort and education, utilizing appropriate psychological consultation and study. The skills and techniques gained will enhance the positive effectiveness of a caring serving professional.

Preparing the exit program involves a combination of compiling all previous evaluations, treat­ment, data, and observation processes in communication with the associated team members to arrive at a conclusion of the involvement process in the patient/client. During the exit program, appropriate recommendations and postdischarge plans are made from the physical therapist’s point of view with preferred sequencing, as well as postdischarge plans for status to returning to full lifestyle situations. Options and variations of any program, as well as reentry into a program, are open for consideration, as is proper application of newly found situations.

Follow-up care resolution is a broad category involved in interpreting the appropriateness and efficacy of the evaluative and treatment process from the patient’s perspective. It also involves the physical therapist’s perspective in the areas of physical ergonomic integration into basic life, con­cepts of preventative physical medicine, appropriate concerns for future update and recheck, and any issue of compliance. This involves a process of communication between the patient and all team members in restoring the patient to the highest level of function and a dignified lifestyle.

Symptom magnification or inappropriate illness behavior is an issue that can be present in the life care process and involves many complications and issues. Physical therapists, as well as other professionals, have attempted to arrive at appropriate systems, tests, and evaluative procedures for giving suitable feedback and baseline data to establish appropriate behavior in any given situ­ation. General considerations for inappropriate illness behavior and symptom magnification are behaviors that are out of proportion to the impairment. It should be understood that symptom magnification is a behavior that is improper but does not implicate a reason or motive for that behavior. Furthermore, it should also be understood that there could be a psychosocial basis for some behaviors that do not necessarily originate from a physiological or organic basis.

In determining symptom magnification or inappropriate illness behavior it should be under­stood that there are often degrees and levels at which it is expressed. Some of these levels are extreme and can impede the appropriate fair process of assisting a person to achieve a healthy lifestyle. In addition, there are forms of symptom magnification that exist on a low level that are intrinsic to basic lifestyle teachings. Therefore, appropriate considerations for establishing objec­tive information, as well as objective treatment, require skill and fitting consultation from the team of life care planners and associated professionals.

If the physical therapist is involved in the identification of the type of symptom magnifier, which could be classified in the areas of an experimenter, a refugee, a game player, and a psychogenic type of magnification, consultation with the appropriate professional should be performed and used (Blankenship, 1989). Appropriate test questionnaires and scales administered by the physical therapist, or previously by associated professionals, can be considered as part of the evaluative
process. It should also be noted that in understanding, evaluating, and commenting on appropriate and inappropriate illness behavior, one should have an open mind and be alert to cross-correlation factors in the evaluative and treatment processes.

An example of this would be a patient being asked to perform a cardinal plane ROM by lifting his arm over his head, but the patient states or demonstrates that he cannot lift his arm above 70° of shoulder flexion. Then when asked to take off his shirt, he is able to demonstrate taking his shirt off over his head, thus demonstrating his ability to flex his shoulders above 100° or more of shoul­der flexion. Cross-correlation of specific evaluative techniques and functional techniques assists in determining the reliability and validity of the patient’s status. In communicating this information, the physical therapist should use the expression “The data presents itself.” Another way to express performance is to use the phrase “The patient demonstrated (this or that).” Therefore, the therapist avoids conjecture and judgment when communicating.

Basic rates in physical therapy for services rendered are wide and varied. Each profession and professional has his or her requirements and specific insights into delivery of any evaluation and treatment process. The following numbers are given as a broad perspective and are estimates for considering lifelong life care planning issues and are subject to change with all basic life situational economics, as well as specific professional demands.

¦     Basic physical therapy treatment and conditioning range from $65 to $200 per hour.

¦    General evaluative techniques, depending on the extensiveness of the techniques, range from $60 to $1000.

¦    These techniques could involve anything from a beginning basic physical therapy evaluation of $65 (average charge) to more specific exams running $200.

¦    WCAs and FCAs range from a modified WCA/FCA costing $200 to a more extensive WCA/FCA costing $1000.

Again, there is such a wide variety in pricing that it is best to be specific to the physical thera­pist involved in the analysis, evaluation, and treatment processes to determine the best life care planning situation. As in other life care planning areas, considerations for “how I would like to be treated” and what is fair should be a basis for appropriate structuring for financial reimbursement.

The physical therapist should establish an appropriate information system in order to accomplish the following:

Provide a means of examining the specific case issues as a professional.Establish appropriate correlations between injury and patient types. Establish appropriate protocol for returning the patient to his or her lifestyle and life situation.Establish appropriate modifications for further patient assistance and study.

The Role of the Occupational Therapist in Life Care Planning

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/exterior

Source: 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.)

Replacement /Service Frequency1-2x (additional visits are possible)Evaluate shoulder/ strength and provide recommendations.Reassess transfer status, train caregivers in lift use if needed, initiate home exercise program for shoulder. See later in plan for PT or personal trainer long-term follow-up.Invacare Reliant battery-powered liftCaregiver use when independent or assisted transfers were unable to be performed.Slings are needed for use with lift.These hours are needed to assist with personal cares, homemaking tasks, and eliminate independent transfers while shoulder pain is present. It is possible hours will be reduced if shoulder pain is eliminated.

¦     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/Service

Frequency

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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