August 2014 Edition

Prepared by Anita Hofmann, MSc OT 1|P a g e

Contact [email protected] for free copies of this manual

TABLE OF CONTENTS

CAOT STUDY NOTES 3

PREPARING FOR AN OT INTERVIEW 139

CAOT NATIONAL EXAM STUDY TIPS 142

SAMPLE CAOT EXAM QUESTIONS 146

SAMPLE CAOT EXAM ANSWERS 210

REFERENCES 215

I welcome any additional tips and suggestions to this manual that may help Canadian OT
graduates who are preparing for the national CAOT exam or job interviews. Contact
[email protected] for submissions.

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CAOT STUDY NOTES

This section includes all the important notes you will need to know categorized by condition.
The conditions are for all areas within the profession that include:

 Neurological conditions
 Pediatric conditions
 Mental health

HINT: Anything that you have covered thus far that falls into a chart or
summary table will be found in these notes. This guide is designed to
make studying easier for you and so that you can make best use of
your time.

IMPORTANT: Know your frames of reference used by OTs for each health condition.

HEALTH CONDITIONS

PART 1 – PHYSICAL HEALTH (Adult & Pediatric)

Amputation

Definition: Amputation is the removal of all or part of an extremity, digit, organ or projecting
part of the body. L/E amputations result from peripheral vascular disease (PVD), chronic
infections, malignant tumours and trauma such as MVA, chemical, thermal or electrical injuries.
U/E amputations most commonly result from trauma (cut, tear, burn, freezing) but may also
occur due to brachial plexus injuries, PVD and diabetes mellitus.

Levels of Amputation:

L/E – complete phalange, partial tarsal or Syme’s (complete tarsal), partial leg (below-knee
[BKA] – upper 1/3, middle 1/3, lower 1/3), complete lower leg with knee disarticulation, partial-
thigh (above-knee [AKA] – upper 1/3, middle 1/3, lower 1/3), complete thigh, complete hip
(through-hip disarticulation/hemipelvectomy)

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U/E – partial hand/transmetacarpal, wrist disarticulation, below-elbow, elbow disarticulation,
above-elbow, shoulder disarticulation

Surgical Procedure:

 involves the provision of a residual limb

 blood vessels and nerves are severed and allowed to retract, bones are beveled and the
muscles are sutured to the bones in a process called myodesis.
 either closed surgery (no drainage) or open surgery (allows drainage) is performed
 most surgical complication involve the skin (ie. breakdowns, ulcers, infected cysts,
allergic reactions, edema, necrotic areas)
 residual limb hyperesthesia, neuromas (balls of nerve tissue), phantom limb (sensation
of the limb that occurs immediately after surgery) or phantom pain
(cramping/squeezing sensation, shooting or burning pain) can interfere with function

OT Theoretical Frame of Reference: Physical rehabilitative, biomechanical

Assessment Process:

 medical history REVIEW MEDICAL RECORDS

 family, work and leisure activities COPM
 sensation testing (touch, pressure, thermal, pain) SEMMES-WEINSTEIN
MONOFILAMENTS TEST, HOT/COLD DISCRIMINATION KIT, PAIN SCALE
 neuromuscular testing MANUAL MUSCLE TEST
 passive and active ROM in joints proximal to the amputation GONIOMETRY
 record limb length and circumference MEASURING TAPE
 psychosocial testing PAIN DISABILITY INDEX, BECK DEPRESSION INVENTORY
 need for adaptive equipment OBSERVATION OF FUNCTIONAL TASK PERFORMANCE

Intervention for L/E Amputation:

1. Preprosthetic Phase (purpose is to learn how to manage the stump and regain lost strength
and endurance):

 to decrease edema: wrap the residual limb (using figure-eight method starting distal to
proximal)
 to promote skin healing, conditioning and prevent pressure sores: inspection of skin
with a long-handled mirror should occur after washing prior to wrapping limb, wash

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 limb daily with mild soap and then pat dry, after edema is gone take circumference
measurements to make sure that the stump is ready for the prosthesis
 to prevent contractures: educate regarding positioning (prone lying is encouraged and
positions such as sitting should be avoided)
 to increase U/E strength and endurance: exercises may be completed using rubber
tubing, elastic bands or strap-on weights and increasing the number of repetitions
 to improve posture: instruct on proper wheelchair positioning and prescribe appropriate
seating
 to decrease pain and desensitize residual limb: methods of decreasing sensitization
include tapping, vibration and constant pressure
 to increase mobility: instruct patient on bed mobility, wheelchair mobility (stump board
should be part of wheelchair) and transfer training
 to assess the home for accessibility: conduct a home visit and make environmental
suggestions

2. Postprosthetic Phase (involves learning to function with a prosthesis):

 to increase mobility: encourage walking on uneven surfaces

 to improve posture: practice balance activities in sitting and standing and attempt
weight-bearing activities
 to assist in developing new body image: educate patient and family about the grieving
process, relay the importance of a prosthetic training program in order for the patient to
integrate the prosthesis into his/her body scheme

Intervention for U/E Amputation:

1. Preprosthetic Phase:

 to facilitate wound care: the residual limb is massaged to discourage scar adhesions,
increase circulation, aid in desensitization and reduce swelling
 to decrease pain and desensitize residual limb: assist in pain control by tapping,
vibration, constant pressure, application of various textures
 to decrease edema: compression using a bandage or shrinker sock, also record residual
limb length and circumference to compare measurements throughout intervention
 to promote skin healing, conditioning and prevent pressure sores: limb should be
washed daily with mild soap, rinsed thoroughly and patted dry, instruct on inspection
techniques and tracking the sensory-impaired limb with vision

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  to maintain passive and active ROM: instruct patient in completing exercises that mimic
and strengthen the movements required to operate the prosthesis
 to increase U/E strength and endurance: use exercises that strengthen muscles in the
shoulder, elbow and scapula, pronation/supination and isometric exercises
 to improve independent living skills status: introduce adaptive equipment, consider
change in hand dominance, practice one-handed techniques, assist patient in doing as
much as possible without prosthesis to encourage self-sufficiency

2. Postprosthetic Phase:

 to improve independent living skills status: practice relevant activities of daily living in
patient’s home environment, consider assistive devices
 to educate regarding prosthetic components: discuss sock hygiene, prosthesis
terminology and function, care of prosthesis, wearing schedule, controls training (grasp
and release), use training, functional training, driving and a home program

Amyotrophic Lateral Sclerosis (ALS)

Definition: The underlying neurological process involves destruction of the motor neurons
within the spinal cord, motor cortex and brainstem. There is a combination of both upper and
lower motor neuron. This group of diseases includes progressive bulbar palsy, progressive
spinal muscle atrophy and primary lateral sclerosis. Affects 1.4-2 per 100 000. There are 2
forms: familial and sporadic. Onset for familial is between 45 and 52 years whereas onset for
sporadic is 55-62 years. Men are affected 3 times more than women The etiology has not been
established. Theories include motor neuron destruction, glutamate insufficiency, metal
toxicity, autoimmune factors, genetic factors and viral infection.

Progressive Bulbar Palsy: areas affected include the corticobular tracts and brainstem nuclei.
Characterized by upper motor neuron involvement and loss of muscles innervated by the
cranial nerves. Symptoms include dysarthria, dysphagia, facial and tongue muscle weakness
and wasting

Progressive Spinal Muscle Atrophy: Characterized by lower motor neuron involvement such as
weakness, atrophy, loss of reflexes and fasiculation of the limbs, trunk and bulbar muscles.

Primary Lateral Sclerosis: Destruction of the cortical motor neurons, may involve both
corticospinal and corticobular. Symptoms include progressive spastic paraparesis.

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Presentation: ALS starts with focal muscle weakness beginning in the arm, leg or bulbar
muscles. Client may drop things, slur their speech, experience abnormal fatigue and emotional
lability. With progression of the disease, marked muscle atrophy, weight loss, spasticity, muscle
cramping and fasticulation (twitching of a muscle at rest) are experienced

ALS is fatal with a mean duration of 2-4 years. Most persons (50%) die within 3 years of onset,
20% live 5 years, 10% live 10 years and some live up to 30 years. ALS does not affect eye
function, cognition, bowel or bladder function or sensation

Prognosis is better if: young age at onset; deficits of either upper or lower motor neuron, not
both; absent or slow changes in respiration; few fasiculations.

Frames of Reference most commonly used by OTs: Physical Rehabiliative, Environmental,

Psychoemotive

Assessments:

1. SMAF: Functional Autonomy Measuring System (5 subscales: ADLs, Mobility, Communication,

Mental Function and IADLs. Administered by interviewing or observations. 65+).

2. Swallowing and eating

3. Occupational Performance History Interview: a 45-60 min., semi-structured, narrative

interview looking at occupational roles, daily routines, activity/occupational choices, critical life
events.

4. Role checklists: 15 minute, self-report questionnaire focusing on persons’ occupational roles

based on MOHO frame of reference.

5. MMT, ROM, balance, coordination (fine and gross motor).

6. Leisure Activities

7. Productivity

Interventions:

Stage 1- Mild weakness, clumsiness

 Energy conservation
 Begin ROM & stretching program

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Stage 2- Moderate, selective weakness

 Adaptive equipment to facilitate ADLs

 Hand orthotic use & orthotic support as AFOs
 Dysphagia evaluation
 Continue stretching to avoid contractures
 Cautious muscle strengthening

Stage 3- Severe, selective weakness in ankles, wrists, hands, becomes easily fatigued with
ambulation, client is still ambulatory

 Prescribe manual or power wheelchair

 Universal cuff to eat
 Begin discussing need for home modifications

Stage 4- Hanging arm syndrome with shoulder pain and edema, depends on w/c for
ambulation, LE weakness

 Arm slings
 Evaluate need for environmental control systems such as voice activated computer
 Heat, massage to control spasms
 Discuss client/family wishes for future intervention

Stage 5- Severe LE weakness, moderate to sever UE weakness

 Family training to learn proper transfer, positioning and turning techniques, assistance
in
 ADLs: Select essential control devices for electric bed, telephone, stereo, etc. Adapt
wheelchair for respiratory device. Psychosocial intervention

Stage 6- Totally dependent-confined to bed/chair

 Evaluate dysphagia & provide with augmentative speech devices

 Continue with PROM, massage

Alzheimer’s Disease

Definition: Progressive degenerative disease of the CNS, destroys brain cells in the cerebral
cortex and hippocampus.

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Presentation: Gradual onset. Impacts higher mental processes, behaviour and mood.

 Memory: primary symptom, followed by apraxia (difficulty selecting and sequencing

voluntary movements), aphasia (expression and understanding of language), agnosia
(loss of ability to recognize objects, people, smells, etc) and impaired executive
functioning (planning, organizing, judgement and performance).
 Visuospatial deficitis.
 Mood: depression anxiety and increased irritability.
 Behaviour: agitation, psychosis (delusions and hallucinations), aggression, wandering,
inappropriate sexual behaviour and day and night disturbances.
 Motor: impaired gait and balance.

Stages of AD:

1) MILD: main characteristics: changes in memory, personality, visual-spatial abilities

 anomia (difficulty producing the right words)- mild word finding difficulties
 may experience occasional agnosia (e.g. doesn’t know what a fork is)
 difficulty with short term memory; mild memory lapses for names, places
 difficulty comprehending/following abstract language
 attention and concentration lapses

2) MODERATE: main characteristics:

 apraxia, confusion, agitation, insomnia

 wandering, repetitive questioning
 usually develop apraxia (e.g. forgets how to use a fork)
 unaware of sensation of thirst or hunger
 catastrophic reactions e.g. extreme emotional responses- hitting, shouting, agitation
 worsening semantic deficits, word-finding; increased use of indefinite pronouns
 pragmatic difficulties with topic maintenance
 reading comprehension difficulties
 difficulty comprehending complex instructions, tasks
 increasing memory deficits for recent events
 social withdrawal
 verbal expression of delusions, obsessive and anxious thoughts

3) SEVERE: main characteristics: aphasia, incontinence, eating difficulties, resistiveness, motor

impairments

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  gross motor actions and coordination declined
 unaware of surroundings
 aphasia (incoherent verbal productions or mutism; severely limited auditory
comprehension)
 repetitive vocal and physical behaviour
 totally dependent in all self-care

4) TERMINAL: bedfast, mute, dysphasia, intercurrent infection

Assessments:

 Cognitive Assessments: MMSE, Cognistat, CCT, Severe Impairment Battery

 Functional Assessments: kitchen tasks, ADLs (Allen Cognitive Level: looks at problem
solving when engaged in tasks), daily routines, home management, driving
 Caregiver Burden: Caregiver’s Strain Questionnaire
 Environmental: home safety assessment

Interventions:

 Cognitive Interventions:
 Sensory Memory Impairment: visual agnosia, sun downing (not recognizing home),
repetitive tactile manipulation, delusions and hallucinations.
 Visual Strategies: enlarged print, high contrast colours, labels, calendars, nametags and
message boards.
 Auditory Strategies: timers, doorbells, hearing aids
 Communication Guidelines: approach the person from the front, use objects to focus
attention on topic, environmental cues like drawings, symbols and labels. Use calm,
positive and unhurried speech; state the client’s name and your name. Use touch for
reassurance and to guide.
 Short-Term Memory, Working Memory and Encoding: repetitive questioning, following
caregiver, difficulty following instructions, agitation and pacing.
 Memory books, cue cards
 Repetitive practice of routine
 Day timers or planners or calendars
 Communication Guidelines: use various types of information (auditory, visual, tactile).
Keep instructions simple, one-step commands and wait for evidence of comprehension,
use encouraging/non-directive language (eg. “lets go take a shower”).

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  Long-Term, Semantic, Episodic and Procedural Memory: difficulty retrieving
information, word finding, remembering person, place and time, lying and accusations,
forgets how to perform basic ADLs, difficulties with phone use and wandering.
 Strategies: signs, memory books, notebooks, diaries.
 Communication Guidelines: use written, tactile, visual, colour, and auditory clues to
enhance access to info; use personal objects, pictures, memory books, familiar music
and smells to trigger associations; use a variety of external memory aids; use 2 choice
questions, “Do you want a or b?”; Avoid “yes/no” questions; establish routines.

Behavioural Interventions:

 Reality orientation: present orientation info (person, place, time) = greater

understanding of their surroundings
 Reminiscence therapy: vocal or silent recall of event’s in a person’s life (alone or group)
 Validation therapy: a therapy for communicating with individuals with AD (assumption:
all behaviour has meaning)

Environmental Interventions:

Tips for caregivers “FOCUSED”:

 F= Face to face e.g. face the client and maintain eye contact
 O=Orientation e.g. repeat key words, repeat sentences verbatim
 C=Continuity e.g. continue the same topic of conversation
 U=Unsticking e.g. suggest a word, ask “do you mean..?”
 S=Structure e.g. provide simple choice questions
 E=Exchange e.g. exchange ideas in conversation, provide clues
 D=Direct e.g. use short, simple sentences; use and repeat nouns, not pronouns; use
gestures

ADLs: encourage participation

Simplify activities: break into smaller steps

Assist with initiating activities, then have person continue

Use cues: visual and verbal

Reduce distractions

Safety: reduce unsafe appliances etc.

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Specific Strategies: Resistance to Bathing: grab bars and bath seat to eliminate fear, food
colouring in the water for visual stimulation, choose appropriate time of day when individual is
rested.

Hoarding: provide a secure space for person to keep belongings, lock important items, and
provide tactilely interesting objects.

Wayfinding: signs and pictures for orientation, nightlights, highlighting colours.

Wandering: motion detectors, leisure activities, routine.

Grooming: eliminate choices, reduce distractions, package required items together.

Arthritis

Rheumatoid Arthritis Definition:

Chronic syndrome characterized by nonspecific usually symmetric inflammation of peripheral

joints usually resulting in progressive destruction of articular and periarticular structures

Cause: Unknown and there is No cure.

Characteristics/Symptoms:

 Fatigue, loss of appetite, fever, overall aching/stiffness, and weight loss

 Onset usually insidious with progressive joint involvement but may be abrupt.
Involvement in joints is usually bilateral. I.e. if one hand is involved then usually the
other is involved as well.)
 Outstanding clinical feature synovitis – inflammation of synovial tissue surround joint.
 Wrist, thumb, and hand most commonly involved
 Usually a loss of ROM, strength, and endurance
 Onset usually around 25-50 however can occur at any age
 2-3 more common in women

Common Associated Deformities:

1. Swan neck: results in PIP hyperextension and DIP flexion which locks the finger reducing
function

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2. Boutonniere: results in DIP hyperextension and PIP flexion which may lock the finger
reducing function

3. Ulnar drift/deviation: involves joint changes especially destruction of and loosening of the
radial collateral ligament.

4. Nabebuff thumb deformities (Type I~ usually seen in RA, Type II~usually seen in OA, & Type
III~both RA and OA).

5. Joint Laxity: instability of the collateral ligaments,

Osteoarthritis Definition: Progressive disorder characterized by altered hyaline cartilage, loss of

articular cartilage, and hypertrophy of bone, producing osteophytes

Cause: Result of a complex system of interacting mechanical, biochemical, and enzymatic

feedback loops (genetics, infection, neurophathic diseases)

Characteristics/Symptoms:

 Pain in earliest symptom. Hips, knees, spine, the first metatarsophalangeal joints,
carpaometacarpal and DIP & PIP jt’s of hand commonly involved
 More common in men before age 45 after 54 women, onset usually in 20’s-30’s.
 Onset is gradual involving 1 or a few joints.
 NOT inflammatory or systemic like RA

Commonly Associated Deformities:

1. Herberden’s Node: osteophyte (node) formation in the DIP’s

2. Bouchard’s Node: osteophyte formation in the (PIP’s)

3. Trigger finger: caused by node or thickening of the flexor tendons of the fingers or thumb as
they pass through the digital pulleys. Nodes on FDS pulleys may block/hinder tendon’s gliding
motion through sheath resulting in a snapping or catching.

Assessments:

 Observation of jt. for warmth, redness, edema, deformity, skin condition, jt.
Enlargement
 Pinch and grip (pinch gauge or sphygmomanometer & dynamometer)
 ROM (goniometer)
 Edema (circumference tape &/or volumeter)

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  Pain (pain scale)
 Functional abilities in ADL’s, work, and Leisure
 Jebsen Test of Hand Function (5 years and over; tests the effective use of the hands in
everyday activities)
 COPM

Interventions:

Guided by biomechanical, compensatory, environmental modification, and assistive technology.

1. Biomechanical: Concerned with structural stability, low-level endurance, edema control,

ROM, strength, and low-level endurance.

2. Compensatory: Teaching compensatory techniques, the use of adaptive & assistive

equipment, and modification of the environments to eliminate barriers to occupational
performance.

3. Energy conservation, assistive devices, joint protection techniques, rest, positioning (good
postural alignment) modalities (heat, TENS, biofeedback) massage (prevents muscle spasm)
therapeutic activity (promote function, strength, and endurance) and ROM exercises.

4. Splinting:

A. Resting hand splint), TX of acute synovitis of the wrist, finger, and thumb

Provides rest to joints and prevent multiple joint contractures.

B. Wrist immobilization splint

Immobilizes wrist while allowing hand to remain functional

Attention Deficit Hyperactivity Disorder

Definition: Three Subsystems 1) Attention deficit only 2) Hyperactive only 3) Combined

Diagnosis: onset prior to 7 years, duration of at least 6 months, pattern of behaviour excessive
for age and intelligence

Epidemiology: up to 10% of greater population, more boys than girls, associated with other
psychiatric disorders and learning disabilities, continued symptoms into adolescence and
adulthood

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Presentation:

 A lack of investment, organization, maintenance of attention/effort in completing tasks.

 An inability to inhibit impulsive action, linked with working memory, self-regulation,
internalization of speech, reconstitution of verbal/non-verbal behaviours.
 A lack of modulation of arousal levels to meet demands of situation.
 Unusually strong inclination to seek immediate reinforcement.
 Restlessness
 Difficulty organizing
 Decreased attention span
 Impulsive speech
 Difficulty following directions
 Forgetfulness

Presentation at School:

 Difficulty staying on task

 Disruptive: fidgets, makes noise, talks, difficulty remaining seated
 Written work: careless and messy
 Poor achievement, incongruent with level of intelligence
 Low self-esteem
 Risk for dropping out of school
 Risk of depression, anxiety and suicide

Assessments:

Consider: 1. General occupational profile to determine ability to perform everyday activities,

school performance, play, and meaningful activities.

2. Sensory integration

3. Motor performance

3. Visual-perceptual skills

4. Behaviour and social skills

Assessment Tools:

1. Sensory Profile: evaluate impact of child’s sensory processing on performance. Parents rate
child’s response on 5-point scale. Considers: sensory processing, modulation (how sensory info

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is regulated) and behavioural and emotional responses to sensory input. Sensory sensitive –
heightened awareness of stimuli. Sensory avoidant – limits sensory stimuli. Low registration –
high threshold for input, slow to respond to stimuli. Sensory seeking – looks for sensory-rich
activities, bored easily.

2. Bruinicks-Oseretsky Test of Motor Proficiency: measures gross and fine motor in kids 4 to 15
y.o.

3. Peabody Developmental Motor Scale (PDMS): evaluate gross and fine motor skills for 0 to 6
y.o. Looks at: reflexes, stationary (body control/posture), locomotion, object manipulation,
grasping and visual motor.

4. Movement ABC: evaluates motor function and impairments. Used with children 4 to 12 y.o.
Examines gross and fine motor with 8 tasks in 3 different areas: manual dexterity, ball skills,
static and dynamic balance

5. Visual Motor Integration (VMI): screening tool for children’s ability to coordinate visual
perception and finger-hand movements. Child copies 24 geometric shapes. There are two
additional tests to determine if the issue is visual perceptual or motor coordination.

6. Social Skills Rating System

7. Behavioural Assessment System of Children

8. Perceived Efficacy and Goal Setting System (PEGS): to be used with children between the
ages of 5 to 10 y.o. Uses cards depicting 24 ADLs and participation in school. Images of child
performing task well and with difficulty; child points to which ever card he or she is more
similar to.

9. Children’s Assessment of Participation and Enjoyment (CAPE): documents how children

participate outside of school, formal and informal activities. Interview format. Used with 6 to
21 y.o.

Intervention:

 Sensory Processing
 Motor Learning
 Skill Acquisition
 Consultative role often required to develop environmental/curriculum modifications for
child.

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  All interventions closely involve parents and teachers to ensure consistency and
enhance generalization.
 Younger children - sensory processing, play, motor abilities, self-help skills
 Elementary aged children - visual perceptual, handwriting, school related tasks,
communication/interaction skills, compensation/remediation of sensory processing
 Older children - vocational skills, study skills, community living, transition planning,
communication/interaction skills

Examples of OT Intervention with Children with ADHD:

1. Environmental modifications – seat cushion, preferential seating, decrease visually

distracting stimuli, quiet space, classroom structure/routine explicitly communicated,
boundaries marked by carpet squares or taped areas of floor.

2. Occupation – assignments broken down in to well-defined steps, schedule of fine and gross
motor activities, keyboard skills and oral communication if handwriting difficulties, improve
routines with charts, checklists, audiotapes.

3. Person

4. Sensory diet – identify sensations that excite/calm child

5. Alert program – to enhance awareness of arousal level and how to make sensory diet choices
to modify arousal level to ‘just right’ level for optimal success.

Autism Spectrum Disorder

Definition: Autism is a neurological disorder classified in the DSM-IV as a subcategory of the

Pervasive Developmental Disorders.

The major features are the Triad of Primary Difficulties:

a) qualitative impairments in social interactions

ex. poor eye contact, lack of social smile, aversion to physical contact,

apparent preference for being alone

b) qualitative impairments in communication

ex. lack of speech (mute), echolalic speech, lack of inflection and emotion

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c) restrictive, repetitive, stereotyped behaviour, interests or activities

ex. intolerance of change in routines, resistance to change, perseveration, lack of imaginative

play, deviant motor patterns (hand flapping, rocking)

Other issues:

 Disturbed eating patterns, mental retardation and seizure disorders

 Diagnosis occurs at age 3
 Autism occurs in boys 3-4 times more than girls and the latest statistics suggest that
1/200 Canadian children is diagnosed with autism.

Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) is the term commonly
given due to the variation in the intensity of symptoms.

Other Pervasive Developmental Disorders include: Rett’s Disorder, Heller’s Syndrome, PDD not
otherwise specified and Asperger Disorder.

Asperger Disorder is differentiated from ASD most notably in the areas of intelligence and
communication. Asperger Disorder is characterized by no general delay in spoken language but
deficits in pragmatics, no general delay in cognitive or adaptive skills, sustained social
impairments but not withdrawal, impairments in non-verbal communication, motor clumsiness
and unusual, restrictive behaviour/activities/interests. This disorder is sometimes described as
“higher functioning autism”.

Assessments:

Areas to Consider:

 Sensory Integration
 Gross Motor Coordination
 Fine Motor Skills
 Social Interaction and Communication
 Visual Perceptual Skills
 Visual Motor Skills
 Basic Concepts
 Play Skills

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Assessment Tools:

1. Sensory Profile: evaluate impact of child’s sensory processing on performance. Parents rate
child’s response on 5-point scale. Considers: sensory processing, modulation (how sensory info
is regulated) and behavioural and emotional responses to sensory input.

2. Sensory sensitive – heightened awareness of stimuli.

3. Sensory avoidant – limits sensory stimuli.

4. Low registration – high threshold for input, slow to respond to stimuli.

5. Sensory seeking – looks for sensory-rich activities, bored easily.

6. Child Autism Rating Scale (CARS): observation tool or 2 and older, distinguishes autism from
developmental delay

7. Preschool Play Scale: Describes children’s capacity for play, their interest areas, and profile
play skills. Areas: space management, materials management, imitation and participation

8. Test of Playfulness: 3 months to 15 y.o. Looks at: perception of control, source of motivation,
suspension of reality, intrinsic motivation, internal control, framing (giving and reading cues)

9. Beery Test of Visual Motor Integration

10. Bruinicks-Oseretsky Test of Motor Proficiency: measures gross and fine motor in kids 4 to 15
y.o.

11. Movement ABC: evaluates motor function and impairments. Used with children 4 to 12 y.o.
Examines gross and fine motor with 8 tasks in 3 different areas: manual dexterity, ball skills,
static and dynamic balance

12. Diet Logs

Intervention:

Focuses on communication, social skills, play skills, sensory impairments and behaviour
modification.

Large variability in clinical presentation, intervention must be highly individualized and

continuously re-evaluated as behaviours are often inconsistent.

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Sensory integration/modulation approach. Examples of OT intervention from a sensory-based
approach include sensory diet, weighted vest, Move & Sit cushion, fidget toys, Wilbarger
protocol.

Intensive Behavioural Intervention. OT’s are generally not involved in IBI but may provide
consultation to IBI therapists or families interested in this approach. IBI uses principles of
operant conditioning to teach children how to respond when presented with specific words and
environmental stimuli. Methods in IBI are based on the theory that children with autism do not
learn spontaneously from their environment and need to be taught everything they need to
learn.

Other interventions include: speech language therapy, special education, diet modifications,
medication, music therapy, vision therapy, family support and education.

Brachial Plexus Injuries

Definition:

1. Peripheral nerve injury

Typically occurs during a breech delivery

 Erb-Duchenne Palsy: unilateral and related to upper brachial plexus. Result of stretching
the shoulder in extreme flexion.
 Klumpke’s Palsy: lower brachial plexus, more severe

Presentation:

Weakness and wasting of the small muscles of the hands and sensory diminuation

Erb-Duchennes: Paralysis of the arm with arm held in characteristic posture (shoulder
adducted, internally rotated, elbow extended, forearm pronated and wrist flexed)

Klumpke’s: paralysis of the hand and wrist muscles

Assessments:

MMT, ROM, goniometry, dynamometers, fine motor and gross motor activities, pain, edema

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WeeFIM: documents level of assistance needed by children with disabilities between the ages
of 6 months and 7 years.

Intervention:

 Positioning: partial immobilization and positioning to prevent contractures; includes

sling
 Passive and active ROM exercises: prevent contractures, increase use, joint mobilization
 Sensory activities: provide sensory input with diverse textures, eg. place rattle in infants
hand
 Massage: decrease edema
 Resistive exercises
 Assistive Devices: compensatory strategy
 NDT
 Proprioceptive Neuromuscular Facilitation (PNF)

Cardiovascular Disorders

Definitions:

1. Cardiovascular disease affects the blood supply, tissues, and muscles in and around the heart
and the vascular system of the body.

2. Hypertension: Elevated systolic blood pressure (bp) at or above 140mm and/or diastolic bp at
or above 90mm of mercury.

3. Orthostatic hypotension: Excessive fall of bp typically greater than 20mm systolic or 10mm
diastolic of mercury in upright posture and is not considered actual disease rather a
manifestation of abnormal regulation.

4. Syncope: Sudden, brief loss of consciousness, with loss of postural tone (fainting).

5. Arteriosclerosis: An arterial wall becomes thickened and loses elasticity. Atherosclerosis is

most common type of arteriosclerosis and is characterized by patchy subintimal thickening
(atheromas or plaques) of medium and large arteries, which can reduce or obstruct blood flow.

21 | P a g e
6. Coronary artery disease: includes angina pectoris and myocardial infarction. Angina pectoris
is a syndrome due to myocardial ischemia typically precipitated by exertion and relieved by rest
or nitroglycerin. Myocardial infarction (necrosis) usually results from abrupt reduction in
coronary blood flow to a segment of myocardium or heart muscle.

7. Heart Failure: myocardial dysfunction resulting from a plasma volume increase with liquid
accumulating in the lungs, abdominal organs (e.g. liver) and peripheral tissues.

8. Shock: Blood flow to and perfusion of peripheral tissues are inadequate to sustain life
because of insufficient cardiac output or maldistribution of peripheral blood flow.

9. Arrhythmias: Bradyarrhythmias (slow) and tachyarrhythmias (fast) causing marked

symptoms of dizziness or syncope (sudden decrease in bp).

10. Cardiac arrest: absent or inadequate ventricular contraction that immediately results in
systemic circulatory failure.

11. Valvular heart disease: occurs when the mitral, tricuspid and aortic heart valves fail to
function properly.

12. Endocauditis: Inflammation of the endocardium of the heart.

13. Pericardial disease: congenital anomalies and acquired disorders.

14. Diseases of the aorta: aneurysms, aortic dissection, inflammation, and occlusion.

15. Peripheral vascular disorders: affect the arteries, veins, and lymphatics of the extremities.

Etiology: Blood clots (thrombus or embolus), thickening of the artery walls (arteriosclerosis),
bacterial infections that result in damage to the valves, high bp, arrhythmias, and other
contributing or lifestyle factors, such as diet/ nutrition, lack of exercise, high-stress, and poor
health habits.

Heart failure usually starts with L-ventricular failure due to coronary artery disease,
hypertension, or congenital defects of the heart.

Presenting Symptoms:

 Chest pain, pain in men may radiate to the back, jaw, or left arm.
 Dizziness
 Cold sweat
 Muscle weakness

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  Shortness of breath
 Fatigue
 Ataxic gait
 Glassy stare
 Decreased endurance
 Anxiety/ fear of dying or symptoms which may lead to inactivity in occupations.
 Depression, decreased self-concept or self-esteem, loss or change of life roles.

Assessment:

Classes of Cardiac Disease

Class I: Clients have cardiac disease but no limitations of physical activity. Activity does
not result in fatigue, palpitation, dyspnea, or anginal pain.

Class II: Clients have cardiac disease resulting in slight limitation of physical activity.
Ordinary activity results in fatigue, palpitation, dyspnea, or anginal pain. They are
comfortable at rest.

Class III: Clients have cardiac disease resulting in marked limitation of physical activity.
Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
Comfortable at rest.

Class IV: Clients have cardiac disease resulting in a inability to carry on any physical
activity without discomfort. Symptoms of cardiac insufficiency or anginal syndrome
may be present even at rest. Activity results in increased discomfort.

Blood Pressure: at rest – 140/90 is considered to be normal.

Heart Rate (pulse) – 60 to100 beats per minute.

Physical Assessment: muscle strength, ROM, gross/fine motor coordination, sensation, and
physical endurance and activity tolerance.

Self-Care: Assess: ADL’s requiring reaching overhead with UE’s which may cause dyspnea
(shortness of breath), chest pain, fatigue, dizziness, or general weakness. Client may avoid
many ADL’s to avoid such related symptoms.

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- Assess risk behaviors such as poor diet, smoking, and exposure to daily stressors.

Productivity: Obtain a work history, and conduct a job analysis including amount of
dynamic/static work being done, energy requirements, and psychological stress. Explore other
meaningful productive options if current roles put client at increased risk for cardiopulmonary
disorders or aggravating current disorders.

Leisure: Explore meaningful leisure pursuits and assess fit in terms of metabolic costs in lieu of
their presenting symptomology.

Intervention:

Four Phases of Cardiac Rehabilitation Programs

Phase I (inpatient stage): Focus is on early mobilization, ROM exercises, resumption of

self-care activities, psychological support, education on disease process, energy
conservation, pacing, and work simplification.

Phase II (early post-discharge stage): Focus on conditioning, assessing risk factors,

continuing education on psychological reactions (e.g. fear of symptoms/death), gradual
return to work/leisure occupations increasing independence of work and self-care roles.

Phase III (outpatient management): Focus on encouraging increased participation in

work roles through modified work duties, assistive devices, environmental adaptations,
and occupation based interventions to enable independent functioning while
minimizing energy consumption and various stressors in the workplace and home
environments.

Phase IV (long-term management): Focus on secondary prevention (e.g. lifestyle

changes), encourage change in personal behaviors (e.g. promotion of exercise) and
reinforce risk factor modification principles in all life roles.

Educate client in task simplification, setting priorities, pacing, energy conservation, work-rest
cycles, body mechanics, stress management/relaxation techniques, disease process and
promote activity through daily occupations in all life roles. Grading of various activities may be
most appropriate to build activity tolerance, endurance, and maximize independent
functioning.

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Provide adaptive equipment to prevent raising of arms above shoulder excessively to promote
independence in ADL’s (e.g. reacher).

Instruct client to monitor symptoms through performance of daily occupations.

Promote healthy lifestyle changes to minimize risk (e.g. exercise and diet etc.) and allow client
to be an active participant (e.g. preparation of meals / preferred exercise medium).

Provide gradual return to work program / work hardening program to increase work related
activity tolerance.

*Cerebral Palsy

Definition: Nonprogressive abnormality in the developing brain. Can impact: motor

performance, cognition, sensory and psychosocial

1. Spastic CP: most common; due to lesion in the motor cortex; normal muscle groups which
usually work together (one contracts, other relaxes) become active together and block effective
movement – this is called co-contraction

2. Athetoid or Choreo-athetoid CP: due to lesion in the basal ganglia; causes difficulty in

coordinating and controlling movement. Affects activities requiring eye-hand coordination

3. Ataxic CP: due to lesions in the cerebellum. Results in weakness, incoordination and
intention tremor. Difficulty with rapid or fine movements.

Terms often used to describe athetoid movements:

1. athetosis: slow, writhing movements

2. ataxia: unsteady walking and balance

3. chorea: abrupt movements of limbs or head

4. dystonia: twisting movements and postures

5. Mixed type: due to lesions in pyramidal (motor cortex) and extrapyramidal (outside motor
cortex, eg. basal ganglia or cerebellum) tracts, which affect both muscle tone and voluntary
movements (i.e. spastic diplegia)

Presentation:

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  Retention of primitive reflexes
 Variable tone
 Abnormal postures because of a lack of muscle co-activation
 Hyperresponsive tendon reflexes
 Asymmetry in the use of extremities
 Clonus: a series of involuntary muscular contractions due to sudden stretching of the
muscle.
 Poor sucking or tongue control
 Involuntary movements

Assessments:

1. Gross Motor Function Classification System for CP: Five levels, level 1 walks without
limitations to level 5 self-mobility is severely limited even with assistive technology

2. Gross Motor Function Measure (GMFM): evaluate change in gross motor skills of children
with CP. Appropriate for children who’s gross motor is below age 5. Involves gross motor
activities such as: lying, rolling, crawling, kneeling, sitting, standing, walking, running and
jumping.

3. Quality of Upper Extremity Skills Test (QUEST): evaluate upper extremities movements in
children with CP. Shows change over time. Compares right and left side. Looks at: dissociated
movements, grasp, protective extension, weight bearing

4. Pediatric Evaluation of Disability Inventory (PEDI): assesses functional deficits of children 6

months to 7.5 y.o. Looks at: functional skills, level of caregiver assistance and modifications for
self-care, mobility and social function. Parents respond to questions and rate performance

5. PEGS

6. CAPE

7. WeeFIM

8. Peabody (0 to 6 y.o.)

9. Reflexes

10. Hand function

11. Play

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12. Cognition

13. Communication

14. Environment

Intervention:

 Neurodevelopmental therapy (NDT): uses specific handling technique to develop motor

control facilitates movement by: proper alignment; guided speed of movement;
inhibiting inefficient movements
 Dynamic Systems Theory: considers goal-oriented movements and transitional periods.
Goal is to enable the use of movement solutions that client discovers. Need to consider
the child, task and environment.
 Assistive Devices
 Environmental Modifications
 Seating and positioning
 Splinting, serial casting and orthosis

Down Syndrome

Definition: Chromosome disorder resulting in developmental delay, a characteristic face and

short stature.

Presentation: Learning: difficulty learning daily living skills, most successful with jobs that
require repetitive tasks

Feeding: difficulty eating due to forward positioning of tongue and underdeveloped chewing
muscles

Hypotonicity: low muscle tone, floppy infant, hypermobility of joints

Hands: short and broad, limiting dexterity

Endurance: congenital heart disease may limit endurance

Muscle weakness

Poor bilateral coordination and midline stability (decreased kinaesthetic awareness)

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Cognition: subnormal intelligence, concentration, problem solving

Assessments:

Area to Consider:

 Motor Skills: developmental milestones, gross motor skills, coordination, ROM, fine
motor skills
 Physical: postural control, balance, muscle tone, reflex development, maturation
 Sensory: modulation, discrimination
 Cognition: attention, concentration, problem solving, decision making, learning,
memory
 Psychosocial: self-perception, coping, social interaction and communication

Assessment Tools:

1. Bruinicks-Oseretsky Test of Motor Proficiency: measures gross and fine motor in kids 4 to 15
y.o.

2. Peabody Developmental Motor Scale (PDMS): evaluate gross and fine motor skills for 0 to 6
y.o. Looks at: reflexes, stationary (body control/posture), locomotion, object manipulation,
grasping and visual motor.

3. Movement ABC: evaluates motor function and impairments. Used with children 4 to 12 y.o.
Examines gross and fine motor with 8 tasks in 3 different areas: manual dexterity, ball skills,
static and dynamic balance

Intervention:

 Feeding: decrease oral sensitivity and work on chewing movements.

 Sensorimotor: with infants work on handling, positioning, watch for neck instability
 Muscle strengthening for stability and joint ROM, gross motor skills with play (rolling,
propping, creeping)
 Reflexes: work on reflex development with bouncing on a ball and tilting in air
 Tactile activities: play with different textures, temperatures, water etc.
 Vestibular input: play with climbing, riding, sliding
 Balance activities

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Developmental Coordination Disorder

Definition: Impairment in development of motor coordination that interferes with ADLs and
academic achievement.

Presentation: Delays in achieving developmental milestones. Clumsiness, difficulty with sports

and handwriting

Assessments:

Areas to Consider:

 Fine and gross motor, eg. ball catching

 Kinesthetic awareness
 Functional performance at home and school
 Self esteem
 Social inclusion
 Coping strategies

Assessment Tools:

1. PEGS

2. Clinical Observations of Motor Postural Skills (COMPS): a brief screen for 5 to 15 y.o. to
determine if further assessment is needed. Takes 10 minutes, involves child copying therapists
movements (slow movements, rapid forearm rotations, finger-nose touching, prone extension
posture, ATNR, supine flexion posture)

3. Movement ABC: describes motor impairments by using quantitative and qualitative

observations. For ages 4 to 12. Looks at: gross and fine motor skills, coordination, static and
dynamic balance

4. Bruinicks-Oseretsky Test of Motor Proficiency: measures gross and fine motor in kids 4 to 15
y.o.

5. Peabody Developmental Motor Scale (PDMS): evaluate gross and fine motor skills for 0 to 6
y.o. Looks at: reflexes, stationary (body control/posture), locomotion, object manipulation,
grasping and visual motor.

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Intervention:

 Cognitive Mediation: top down approach based on cognitive-behavioural and motor

theories.
 Cognitive Orientation to Occupational Performance (CO-OP): works on skill acquisition,
development of cognitive strategies and transfer of skills to other environments and
tasks. Involves “talking therapy”, verbalization of the skill (Goal-Plan-Do-Check)
 Motor Learning: repetition of task

Evidence-Based Practice and Research/Statistics

Evidence-Based Practice (EBP): An approach to decision making in which the clinician uses the
best evidence available in consultation with the patient to decide upon the options which suits
that patient best

Sources of Knowledge/Evidence:

1. Tradition: when most people believe it is true

2. Expertise: experts believe it is true

3. Experience: when it fits one’s personal experience

4. Research: supported by results of scientific investigation

5. Intuition: idea that just feels right

6. Parsimony: when an idea is the simplest alternative

7. Credibility: idea comes from a valid and convincing source

8. Triangulation: idea is supported by multiple sources

Evidence Based Practice Process:

1. Identify question

2. Literature search

3. Focus or broaden question

30 | P a g e
4. Identify and retrieve relevant reports

5. Appraise evidence

6. Decide whether or not to change practice

7. Plan and make change

8. Evaluate effect of change on clients

Hierarchy Levels of Evidence of Evidence Based Practice: (Moore et al. as cited in Holm, 2000)

1. Strong evidence from at least one systematic review of multiple RCT’s

2. Strong evidence from at least one RCT with appropriate sample size

3. Well designed non randomized trials,

4. Single group, pre-post, cohort, time series, matched case control studies

5. Well designed non experimental studies from more than one center/research group

6. Quasi-experimental; triangulation

7. Opinions of respected authorities based on clinical evidence, descriptive studies or reports of

expert committees

Quantitative Design Study Design:

1. & 2. Randomized Control Trial (I & II). Clients are identified and then randomly allocated into
the treatment groups with a control and experimental group

Participants → Stratification → Randomization → Outcome

3. Cohort Design (III)

Prospective design in which a cohort is followed and observed over time to see what happens
and often compared to a control group.

Exposure to intervention

Participants→ Outcome

No exposure to intervention

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4. Single Case Design (III)

Prospective design which only involves one client or number of clients. Evaluation of the clients
for the outcome of interest before and after the intervention

Baseline

Individual client → Evaluation → Intervention → Evaluation → Intervention

5. Before-after Design (III)

Prospective design which evaluates clients involved in a treatment however there is no control
group

Participants → Assessment → Intervention → Outcome

6. Case Control Design (III)

Retrospective design looking at a set of clients with a defining characteristics and compare
them to a control group to determine the differences between the two groups. Participants
with outcome of interest. Assessment of previous exposure - Compare - To intervention or
causal factor between groups - Participants without outcome of interest

7. Cross-sectional Design (IV)

Evaluation of a group is carried out at the same time . E.g. surveys, questionnaires

8. Case Study Design (IV)

To provide descriptive information to explore a new topic or treatment where there is no

control group

Biases:

 Sample/Selection
 Volunteer or referral
 Seasonal (i.e. timing of recruitment)
 Attention (i.e. paying more attention because part of a study)
 Measurement/Detection
 Number of outcome measures used (too many or too few)
 Lack of “masked” or “independent” evaluation
 Recall or memory bias

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  Intervention/Performance
 Contamination
 Co-intervention
 Timing of intervention
 Site of treatment
 Different therapists

Qualitative Design Study Designs

1. Ethnography

 Story of a group’s daily life, to identify the cultural meaning, beliefs and patterns of a
group
 Investigators are immersed in the culture

2. Phenomenology

 Phenomenon of a lived experience from the perspectives of those who are living the
experience

3. Grounded Theory

 Inductive in nature in which theory is constructed and verified

4. Participatory Action Research

 Individuals and groups researching their own personal beings, socio-cultural settings &
experiences in which the researcher works in partnership
 They reflect on their values, shared realities, collective meaning, needs and goals.
 Knowledge is generated and power is regained through actions that nurture, empower,
and liberate

Endogenous

 Insider as the researcher and subject as research (E.g. investigating prison violence)

Critical Theory

 To understand experiences of social change and deconstruct the notion there is a

unitary truth

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Heuristic Research

 To reveal personal and lived experiences . Knowledge emerges from personal

experience

Life History

 Biographical experience which examines social, cultural & political context. E.g.
Congenital quad and the meaning of disability

Quality Issues ofQuanlitative:

 Trustworthiness: extent to which findings can be viewed as worthy of confidence and

attention
 Credibility: integrity & rigor
 Transferability: applicability
 Dependability: reasons for variability identified
 Conformability: grounding of data and interpretations

Techniques:

 Procedural Rigor
 Auditability
 Triangulation
 Reflexivity
 Member checks/peer review
 Saturation

Process:

 Coding
 Categorizing
 Forming Themes

Statistics

Descriptive Statistics: Stats that describe, organize, and summarize data. They include things
such as frequencies, percentages, descriptions of central tendency (mean, median, mode), and
descriptions of relative position (range, standard deviation).

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If a non-experimental research design is employed, almost all of the data will be appropriately
analyzed descriptively because random selection may not have been used for the sample and
there may not be a control group.

It is difficult to make inferences from a sample to a population (the purpose of inferential

statistics) if random sampling and control criteria have not been met.

The initial description and compilation of data can be achieved using descriptive statistics so
that the reader has a thorough understanding of the subjects and variables.

It is customary to present percentages alongside frequencies, both in the text and in illustrative
tables.

Inferential Statistics: Allow one to make inferences from the sample to the population in order
to speculate, reason, and generalize about the population from the sample findings. The types
of statistical tests used in inferential statistics include t-tests, F tests, and tests for r. These tests
result in probability statements that help to draw conclusions about differences or relationships
between groups.

Allow us to take the results from a research project and decide whether those findings are likely
to occur in the target population.

If there is a statistically significant result, we may decide that the probability is great that we
have in fact found a result that can be generalized to the target population.

Tests for inferential stats can be divided into three groups:

Those that try to find if the differences observed between 2 sets of scores are significantly
different.

Those that examine 2 sets of scores to find the strength of association between them

Those tests that compare more than 2 sets of scores to find the extent to which they vary
together.

Reliability: A reliable measure is measuring something consistently, but not necessarily what it
is supposed to be measuring.

Testing Reliability: Test-retest reliability – the same group of people is tested at two different
times with the same test. The correlation between these two scores is a measure of its
reliability and measures the measurement error inherent in a test due to the passage of time.

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Interrater reliability – the correlation between the scores of two independent observers. A
good test/assessment will be developed to keep this high. This is done through standardized
administration and scoring guidelines. If interrater reliability is high, the scores have more
credibility because you can be certain that the same score would have been obtained no matter
who did the testing.

Validity:

 Construct validity – the degree to which the testing tool and measurement tool used in
a study accurately reflect the conceptual question of interest. For instance, asking
people whether they feel that a product is usable is not necessarily an accurate measure
of how effectively they can use it.
 Face validity – does a procedure appear to measure what it claims to measure?
 Internal validity – is there another reason that might explain the outcome of our
experimental procedure? An experiment is said to possess internal validity if it properly
demonstrates a causal relation between two variables.
 External validity – also known as generalizability. The possibility of applying the results
of an internally valid experiment to other situations and other research participants.

Correlation: Defined as a statistical technique for determining the degree of association

between one or more variables. Correlation does not imply causation; a third variable might be
at work.

Correlation coefficients (represented by r) range from –1 to +1. –1 being a strong negative

correlation. 0 being no correlation and +1 being a strong positive correlation:

Strong Negative Correlation

12
10
Accidents per year

Strong Negative Correlation

8
6 r = -1.0
4
2
0 As household income increases, the
20 30 40 50 60 70 80 90 100 110 number of car accidents per year
Income (X1000) decrease.

36 | P a g e
 Strong Positive Correlation

12
10 Strong Positive Correlation
Accidents per year

8
r = 1.0
6
4
2
As household income increases, the
0
20 30 40 50 60 70 80 90 100 110 number of car accidents per year
increase.
Income (X1000)

No Correlation

8 No Correlation
7
Accidents per year

6 r=0
5
4
3
2
1 No relationship between household
0 income and number of car accidents.
20 30 40 50 60 70 80 90 100 110

Income (X1000)

Hypothesis Testing: Is it possible that the results obtained in your experiment due to chance
alone?

Assign a probability to the statement that our results are not due to chance alone. That is, our
study results could have happened by chance only one time out of every 100. The probability
that is set is called the alpha level (probability of rejecting the null hypothesis when it is true)
and is represented by p<0.01, p<0.001 or p<0.05 (1%, .1% or 5% chance that we think that our
experiment shows results that are not due to chance but really are). It is a way of saying “I’m
99.9% sure that what I’m proposing here is correct”.

Non-parametric Data:

 Nominal Data - the numbers applied to non-numerical variables (e.g. eye colour may
be coded as: blue=1, brown=2, etc.). Grouping the data into categories.

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  Ordinal Data - numbers that still are discrete, but are ordered. However, the intervals
between the categories are not known and cannot be assumed to be equal. (e.g. Likert
scale: Strongly agree, agree, neutral, disagree, strongly disagree). Ordinal data are
presented by counting the number of cases (frequency) of each ordered rank making up
the scale. (REFER TO PAGE 187 in Polgar & Thomas)

Parametric Data:

 Interval Data - are also ordered in a logical sequence. However, this time the intervals
between the numbers are considered equal and represent actual amounts. These are
continuous data.

 Ratio Data - numbers that are continuous with equal intervals between numbers, with a
meaningful zero point.

Rules That Need to be Applied to the Distribution of Data in Order to be Able to Use
Parametric Tests: The sample must be representative of the target population so that the
variables being measured fall within the normal distribution for that population (for example,
random selection has occurred).

Variables must have been measured in a manner that generates interval or ratio data.

Initial differences between subjects in the two groups under study must have the opportunity
to be similar (e.g random assignment to groups or matching must have occurred).

When any of these conditions has not been met, non-parametric statistics should be used

Significant Differences: The tests assist the researcher to decide whether or not the changes in
the mean scores of the experimental group are, in fact, due to experimental treatment, rather
than due to chance.

Pearson’s Chi-Square Test: In this test, the data used for analysis are counts of category
membership (e.g. how many subjects are women, how many are men?)

This test can be used when you wish to know if there are significant differences between pre-
test and post-test scores for a given group, or if you wish to know if 2 groups are similar when
you intend to use one as an experimental group and one as a control group.

It can be used to compare groups on a single variable or on groups of variables, one at a time.

38 | P a g e
This test is useful when the researcher is interested in similarities between groups of subjects.

T tests: There are 3 different t tests which are each used with a different research design, but
all compare the mean scores of 2 groups.

Single sample t-test: compares the mean for a sample against a known population mean for a
particular variable (rarely used).

Paired groups t-test: used when subjects have been used as their own control group and when
subjects have been matched on some characteristic. (the pre-test and post-test means are
compared for the first group and two scores from the matched pairs are compared for the
second group).

Independent groups t-test: the pre-test and post-test means are compared for the
experimental and control groups, and the two post-test scores are compared

Wilcoxon Signed Rank Test: Used on non-parametric data and is equivalent to the correlated
groups t test. It is performed on paired scores and will determine the significance of the
difference between either pre-test and post-test scores for individuals.

Wilcoxon Rank Sum Test: Equivalent to the independent groups t-test but is used on non-
parametric data. For this test, ranks are assigned to scores for all subjects in the study and the
ranks for all subjects in each group are assumed. Then this test determines the degree of
differences between group total scores

Mann-Whitney Test: Tests for differences between means on 2 independent groups and is
equivalent to the independent groups t-test.

Tests for Correlation: These tests are used to examine 2 sets of scores to find the extent of their
relationship to one another. The 2 sets of scores might be from one set of individuals or from
two different groups of individuals. Once it is seen that one score moves up or down, the intent
is to find out if the other score moves in a corresponding fashion. If both scores increase
together, they are said to be positively correlated.

Negatively correlated = if one score increases while another decreases.

Tests for correlation yield a statistic called a correlation coefficient, expressed as r.

An r may range from -1 (indicating a perfect negative relationship) to +1 (indicating a perfect

positive relationship). A 0 would indicate no relationship between the 2 variables.

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Pearson Product Moment Correlation: The most common correlation test, often called Pearson
r. Often used to estimate reliability between tests, as in a test-retest situation, or between 2
testers to indicate inter-rater reliability.

Spearman Rho: Is the equivalent to the Pearson r. Used in descriptive research resulting in non-
parametric data when items have been ranked and the investigator wishes to compare 2 sets of
rankings to see if there is any type of relationship between them. Like the Pearson, it results in
an r value between -1 and +1. It is important to remember that a relationship between 2 sets of
scores does not necessarily mean there is a cause-effect relationship.

Regression Analysis: A technique that can be used after the correlation coefficient has been
established. When a relationship has been found between 2 variables, one can attempt to
predict future scores for the dependent variable based on the scores on which the correlation
coefficient was found.

Comparison of More Than 2 Variables:

1. Analysis of Variance (ANOVA)

A stats technique that can compare the mean scores of 3 or more groups in one study.

Yields an F ratio

2. Analysis of Covariance (ANCOVA)

It controls for initial differences between groups

By making the groups more equitable to begin with, the final results can be compared and
judged more fairly.

Kruskal-Wallis Tes: Equivalent to one-way ANOVA and can be used on non-parametric data

Multiple Regression: This test provides a way of making predictions about the study variable by
understanding the effects of 2 or more independent variables on the study variable. (e.g. how
much do the independent variables correlate with the study variable?).

Surveys: “investigations aimed at describing accurately the characteristics of populations for

specific variables” (Polgar & Thomas, 2000, p.86). Commonly used for the following purposes:

 to establish the attitudes, opinions, or beliefs of people concerning health-related issues

(collection techniques often include questionnaires or interviews)
 to study characteristics of populations on health related variables

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  to collect information about the demographic characteristics of populations

The statistics obtained from surveys present us with an overview of the state of health, illness
and treatment patterns in a given community

*Hand Injuries (Anatomy of the Upper Extremity - Review in conjunction with an anatomy
text)

Joints in the hand:

1) Carpometacarpal (CMC) : at the very base of the thumb basically at the wrist. Allows for
flexion, extension, abduction, adduction and rotation. The clinical significance of this joint is
that it is thin and lax in nature, which facilitates the thumb’s most important movement of
opposition; during prehension, the thumb provides the stability for grip by opposing to the
fingers.

2) Metacarpophalangeal (MP): joint in the thumb that allows flexion, extension, abduction,
adduction, rotation and circumduction. This joint provides additional range to the thumb pad
in opposition, permits the thumb to grasp and contour objects.

3) Interphalangeal (IP) of the thumb (joint closest to the tip of the thumb): allows flexion and
extension., known as the epicentre of the hand.

4) Metacarpophalangeal (MCP) of the digits (your knuckles) allow flexion, extension, abduction,
rotation, circumduction. These joints determine the position of the distal joints, they are the
governing joint of the fingers. In normal prehension, the MCP joint flexes last, extends first, is
stable in flexion and mobile in extension.

5) Proximal Interphalangeal (PIP) of the fingers (2nd joint in your fingers) allow for flexion and
extension and are important in control of flexion and extension of the entire finger, this joint is
stable in all positions and has greater range of motion then the distal phalangeal joint.

6) Distal Interphalangeal (DIP) of the fingers (joint at the very tip of your finger) allows for
flexion and extension. This joint places to the tip of the finger in optimum position for
recognizing objects by touch and for precise manipulation.

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Muscles:

1. Extrinsics Flexors (originate in the forearm):

Extrinsic flexor muscles form a prominent mass on the medial side of the upper part of the
forearm. The most superficial group:

a) Pronator teres: innervated by the median nerve and allows for pronation of the forearm

b) Flexor Carpi Radialis: innervated by the median nerve, permits flexion of the wrist, radial
deviation of the hand.

c) Flexor Carpi Ulnaris: innervated by the ulnar nerve, flexion of the wrist, ulnar deviation of the
hand.

d) Palmaris longus: innervated by the median nerve, provides tension through the palmar fascia

Intermediate group:

a) Flexor digitorum superficialis: innervated by the median nerve, flexes the PIP and MCP joints
of the hand.

Deep layer:

a) Flexor digitorum profundus: innervated by the median nerves index to long fingers and the
ulnar nerve for the ring and small fingers, flexes the DIP, PIP and MCP joints.

b) Flexor pollicis longus: innervated by the median nerve, flexes the IP and MP joints of the
thumb.

c) Pronator quadratus: innervated by the median nerve, pronation of the forearm.

All the flexor tendons enter the carpal tunnel beneath the protective roof of the deep
transverse carpal ligaments (aka flexor retinaculum) in company with the median nerve. In the
canal, the common profundus tendon to the long, ring and small fingers divides into the
individual tendons that fan out distally and proceed toward the distal phalanges of these digits.

2. Extrinsic extension muscles:

Extension of the wrist and fingers is produced by the extrinsic extensions muscle tendon
system.

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a) Extensor Carpi ulnaris: innervated by the radial nerve, extends the wrist and ulnar deviation
of the hand.

b) Extensor Digitorum Communis: innervated by the radial nerve, extends the fingers.

c) Extensor digiti quinti proprius: innervated by the radial nerve, extends the little finger

d) Brachioradialis: innervated by the radial nerve, pronation or supination depending on the

position of the forearm, because it inserts on the distal radius it does not truly contribute to
wrist or digit motion.

e) Extensor Carpi Radialis longus and brevis: Both are innervated by the radial nerve and both
are involved in the extension of the wrist and radial deviation of hand.

f) Extensor Pollicis Longus: (EPL) innervated by the radial nerve

g) extends thumb IP joint and b) extends/abducts the thumb at the MP and CMC joint

h) supinator of the thumb MP

i) Extensor indicis proprius: innervated by the radial nerve and extends the index fingers

3. Intrinsic muscles (originate in the hand):

The intrinsic muscles are divided into muscles comprising the thenar eminence, the hypothenar
eminence, and the remaining muscles between the 2 groups; the interosseus and the
lumbricals. The thenar eminence is the palpable bulge of muscles just proximal to the thumb
whereas the hypothenar eminence are the muscles that move your little finger and located just
below your little finger.

4. Muscles of thenar eminence:

a) Abductor pollicis brevis: innervated by the median nerve, abducts the thumb, flexes thumb
at MP and CMC joint..

b) Flexor pollicis brevis: innervated superficially by the median nerve and deep by the ulnar
nerve, flexes and rotates the thumb.

c) Opponens Pollicis: innervated by the median nerve, allows the thumb to oppose the fingers.

d) Adductor Pollicis: innervated by the ulnar nerve, adducts thumb to palm, gives power to
grasp.

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5. Muscles of the hypothenar eminence:

a) Abductor Digiti Quinti: innervated by the ulnar nerve, abduction of the small finger, flexion of
the proximal phalanx, extension of PIP and DIP joints.

b) Flexor Digiti Quinti brevis: innervated by the ulnar nerve, flexion of the proximal phalanx of
the small finger and forward rotation of the 5 MC.

c) Opponens digiti quinti: innervated by the ulnar nerve, draws the 5th metacarpal anteriorly
and rotates laterally for opposition with the thumb

d) Palmaris brevis: innervated by the ulnar nerve, wrinkles the skin of the ulnar side of palm,
deepens the hollow of palm, aiding in grip, covers and protects ulnar nerve and artery.

The strong thenar musculature is responsible for the ability to position the thumb in opposition
so that it may meet the adjacent digits for pinch and grasp functions, whereas the hypothenar
group allows a similar but less pronounced rotation of the 5th metacarpal.

6. The interosseus muscles:

Of the 7 interosseus muscles, 4 are consider the dorsal group and 3 as palmar interossi

The dorsal interossi are innervated by the ulnar nerve and they spread the index and ring
fingers away from the long finger. The palmar interossi are also innervated by the ulnar nerve
and they adducted the index, ring, and small finger toward the finger. The interossi are
important for the movements necessary to type, play the piano, and to write.

7. The lumbricals:

Are innervated by the median nerve from the index to long finger and the ulnar nerve for the
ring and small finger and they supplement MCP flexion and extension of the PIP and DIP joints.
The lumbricals place the fingers in the writing or the billiard cue position.

The Median Nerve: Muscles supplies and cutaneous distribution: pronator teres; palmaris
longus; palmaris brevis; flexor digitorum superficialis; flexor digitorum profundas to the second
and third digits; flexor pollicis longus; pronator quadrates; palmar cutaneous branch; abductor
pollicis brevis; superficial branch to flexor pollicis brevis; opponens pollicis; first lumbrical;
second lumbrical; digital sensory nerves

When the median nerve us severed at the elbow, flexion of the PIP joints of the thumb, index,
and middle fingers is lost and is weakened in the ring and small fingers. Flexion of the DIP joints
of the index and middle fingers is lost as well. The ability to flex the MCP joints of the index and

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middle fingers will be affected. Thus when the patient attempts to make a fist, the index and
middle fingers remain partially extended. Thenar muscles are also lost as in carpal tunnel
syndrome.

The Ulnar Nerve: Muscles supplied and cutaneous distribution: flexor carpi ulnaris; flexor
digitorum profundus to the 4th and 5th digit; abductor digiti minimi (or quinti); fourth
lumbrical; third lumbrical; palmar interosseus muscles; flexor pollicis brevis; adductor pollicis

Ulnar nerve injury commonly occurs where the nerve passes posterior to the medial epicondyle
of the humerus. Compression of the ulnar nerve at the elbow usually produces numbness and
tingling in the medial part of the palm and the medial one and a half of the digits (small and ring
finger). Severe compression may also cause pain that radiates distally. An injury to the nerve
at the distal part of the forearm denervates most intrinsic muscles of the hand, power of
adduction is impaired which can lead to a clawhand appearance, as the interosseus muscles
atrophy.

The Radial Nerve: Muscles supply:

1. Extensor Carpi Ulnaris; Extensor Digitorum Communis; Extensor digiti quinti proprius

2. Brachioradialis; Extensor Pollicis Longus; Extensor Carpi Radialis Longus; Extensor Carpi
Radialis Brevis; Extensor Indicis Pollicis

The radial nerve is often injured when the humerus bone is fracture. This injury is proximal to
the branches to the extensors of the wrist, and so wrist-drop is the primary clinical
manifestation of an injury at this level. If a deeper branch of the nerve is severed it results in an
inability to extend the thumb and the MCP joints of the other digits. To test if a deep branch of
the radial nerve has been cut, ask the individual to extend the MCP’s against resistence.

Frame of Reference Biomechanical Approach: The basic assumption of the biomechanical

approach is that occupation requires the ability to move the limbs (ROM and muscle strength)
and the endurance to persist in movement until the goal is accomplished). Those hand injuries
that result in edema, contractures, joint destruction (arthritis), peripheral nerve injuries, and
cumulative trauma disorders are treated using this approach. The primary mechanism of that
brings about therapeutic change is occupation as a means, that is activities that provide stretch
of soft tissues, AROM, PROM to preserve and restore full range of motion, resistance and other
stress to strengthen weak muscles.

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Assessment of Hand Injuries: There are a number of assessments that can and should be done
when conducting a thorough assessment of a hand injury: As always you want to gather
information about the client such as the:

1) History of the presenting problem - who were they referred by, how long has this been a
problem, what are the symptoms they are experience, any relevant past medical history.

2) Environmental considerations Talk to them about their life, their work obligations and roles,
family roles, and leisure roles....the COPM is appropriate. List the identified occupational
performance issues.

3) Assess appearance of the hand - any edema, scarring, stitches, bleeding

4)Pain rating: get a pain rating 0 - 10 with ten being the worst pain they have ever felt, how
long have they been experience the pain and how many hours of the day is the pain present
and where is the pain felt.

Hand dominance and affected hand

5) Assess ROM of all the digits and all the joints using a goniometer, also want to look at the
quality of the movement, which looks awkward and unpleasant.

6)Assess sensation if necessary (e.g. Semmes Weinstein monofilament): The Semmes Weinstein
measures the threshold of light touch sensation. The person is seated comfortable with their
hand occluded from their eyes and you begin with the smallest monofilament (2.83), hold the
filament perpendicular to the skin and press it down until the filament bends. Repeat three
times on each testing site, using progressively thicker filaments if the patient does not perceive
the thin ones. Evaluation findings are often reported as absent (total loss of sensation), intact
(normal sensation) or impaired (able to detect some but not all of the stimuli or when the
perception of the stimulus is different from that of an area of skin that has intact sensation.
Norms are provided for the Semmes Weinstein by gender and age.

7) Assess edema as necessary (Volumeter): Edema is one of the causes of limited range of
motion and can be assessed by a volumetric measurement. Volumetric measures the mass of
the body part by the amount of water is displaces. For example and edematous hand in placed
into a container filled with water to a spout. The swollen hand is placed into the container and
the amount of water that spills from the spout into a graduated cylinder. An edematous hand
displaces more water than an unswollen hand. So you compared the amount of water spilled
from the swollen hand and the unaffected hand.

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8) Test hand strength with a dynamometer for grasp and pinch (tip to tip, tripod, and lateral)

9) Do provocative tests a) Phalens: (see carpal tunnel syndrome), b) Tinels (see carpal tunnel
syndrome), c) Finkelstein (see deQuervains Tendinitis)

Addition assessment that may be completed as needed are:

1. The Jebsen hand Function Assessmen: tThis assessment consists of seven test items
representative of various hand activities. Each of the subtests were designed to be
administered in precisely the same manner of each subject. Detailed standardization
procedures and instructions are provided for the evaluator. The time of performance is
recorded for each test. Both the dominant and non-dominant hands are tested independently.
The test items include 1) Writing a short sentence. Turning over 3 by 5 inch cards (simulated
page turning). Picking up small objects and placing in a container. Stacking checkers. Simulated
eating. Moving empty large objects (cans) and Moving weighted large objects (cans).

Strengths: The test distinguishes between subjects with and without various types of
physical disabilities. The test provides quantitative measurements of standardized tasks
with norms against which clients performance can be compared. Standardized
instructions and procedures are provided.

Weaknesses: Does not allow the use of adaptive equipment questioned whether the
subtests represent common everyday tasks and whether the subtests simulate the tasks
they wish to measure. Questioned whether non dominant handwriting and timed
handwriting is tested at all.

2. The Purdue Pegboard

The test measures two types of activities (1) gross movement of hands, fingers and arms (2)
fingertip dexterity. Besides individuals with hand injuries, this assessment has been used with
many clinical populations including people with: brain injuries, learning disabilities, visually
impaired as well as in vocational rehab, neuropsychology screening batteries, neurocognitive
deficits in schizophrenia. During the assessment the client is timed on how quickly pegs are put
in holes and pieces are assembled. . It has a wooden board with two rows of tiny holes plus
reservoir for holding pins, collars and washers. The four subtests are performed on the
dominant, non-dominant and both hands with the score being the number of pins placed in 30
seconds. Dexterity is assessed through speed, and the score is compared to existing norms. This
assessment has good test-retest reliability, but validity has not been established in occupational
therapy.

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Type of Hand Injuries:

1. Carpal Tunnel Syndrome

A common condition that is cause by increased pressure is put on the median nerve as it runs
through a narrow tunnel of bone and ligament (transverse carpal ligament) at the wrist. The
median nerve along with 9 tendons pass through this tunnel and when the nerve gets
compressed the symptoms include numbness, tingling, decreased movement in the hand and
wrist, and pain in the arm and fingers. Once the symptoms of pain and tingling appear, the
condition frequently worsens and permanent damage may occur. The pain and numbness can
happen anywhere or anytime, but most symptoms begin at night. The median nerve
distribution provides sensation to the palmar side of thumb, index finger, long finger and the
medial side of the ring finger, as well as motor control to the muscles surrounding the thumb.
Damage therefore affects the hands ability to grasp large and small items. In very severe cases,
sensation may be permanently lost and the muscles at the base of the thumb slowly shrink
(thenar atrophy) However CTS is highly treatable if diagnosed early. CTS may be caused from
repetitive activity, strong grip or pinch causing strong contractions of the muscles in the hands
and fingers, bending the hand up/down/sideways, vibration, awkward postures, and impact (
using heavier tools).

Assessment: a detailed history including medical conditions, how the hands were used, and
whether their had been previous hand injuries. Do a phalens test: have patient hold wrist in a
flexed position for 60 seconds, ask them if their hand feels any different then before the test
and if so, the describe it for you. You could also complete a Tinels test by tapping over the
nerve at the wrist with your fingers and asking the same questions as the phalens test.

Treatment: Symptoms can be relieved without surgery, a person can be taught to change the
pattern of their hand use, or a wrist cock up splint can be made, this splint keeps the wrist in a
neutral position and can be worn while the person sleeps at night or during the day when a
person’s symptoms are acting up. When symptoms are severe, a surgery that cuts the ligament
that is the roof of the carpal tunnel on the palm side of the hand.

2. deQuervain’s Tendinitis

This is a special type of tenosynovitis that occurs in the thumb, as the compartment lining
around the tendons swell, changing the shape of the compartment, which makes it difficult for
the tendons to moves as they should. The swelling also causes pain and tenderness along the
thumb side of the wrist, most noticeable when forming a fist, grasping or gripping things, or
turning the wrist. The tendons involved are extensor pollicis brevis. and abductor pollicis

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longus. DeQuervains is caused by an irritation of the tendons at the base of the thumb such as
awkward positions such as pinching with the thumb in conjunction with movement at the wrist
such as polishing, wringing out clothes and using pliers.

Symptoms: the pain over the thumb side of the wrist is the main symptom and may appear
gradually, or suddenly. It is felt in the wrist and can travel up the forearm. Swelling over the
thumb side of the wrist is usually noticeable and may accompany a fluid filled cyst in this
region. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the
back of the thumb and index finger.

Assessment: A finkelstein test: in which the patient is asked to make a fist with fingers over the
thumb. The patient is then instructed to bend the wrist in the direction of the little finger. This
test can be very painful for the person with deQuervains.

Treatment: goal is to relieve the pain caused by the irritation and swelling. May make a splint, a
short or long thumb spica is appropriate. Anti-inflammatory medication taken by mouth or
injected into the tendon compartment may help reduce the swelling and relieve the pain.
Simply not doing the activities that aggravate the condition is good advice.

3. Trigger Finger

Trigger finger also known as stenosing tenosynovitis, involves the pulleys and tendons in the
hand that bend the fingers. The tendons work like long ropes connecting the muscles of the
forearm with the bones of the finger and the thumb. In the finger the pulleys form a tunnel
under which the tendons must glide, and these pulleys hold the tendons close against the bone.
Trigger finger/thumb happens when the tendon swells, it must squeeze through the opening of
the tunnel which causes pain, popping or catching feeling in the finger or thumb. When the
tendon catches, it produces inflammation and more swelling. Sometimes the finger becomes
stuck (locked) and is hard to straighten or bend. The cause of this condition is not clear, but has
been linked with rheumatoid arthritis, gout, and diabetes.

Symptoms: May start with discomfort at the base of the finger or thumb. A thickening may be
found in this area. When the finger begins to trigger or lock, the patient may think that
problem is at the middle knuckle of the finger or the tip of the knuckle of the thumb.

Treatment: Therapy consist of splinting the MCP in neutral to prevent triggering while
promoting tendon glide.

4. Flexor Tendon Injuries

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Tendons in the hand and forearm: The flexor muscles are able to move the fingers through cord
like extensions called tendons, which attach muscle to bone. The tendons of the flexor muscles
that lead to the fingers and the thumb begin just beyond the middle of the forearm. The thumb
has one long flexor muscle (flexor pollicis longus) and the middle fingers each have two flexor
muscles. One tendon (the flexor digitorum superficialis) attaches to the middle bone of each
finger on the palm side of the hand and bends the fingers at the base(MCP’s) and second joints
(IP’s). The other tendon(flexor digitorum profundus) attaches to the bone at the tip of each
finger on the palm side and bends all three joints. Deep cuts on the palm side of the wrist,
hand, or fingers can injure the flexor tendons and nearby nerves and blood vessels. When a
tendon is cut, it acts like a rubber band and its cut ends pull away from each other, making a
simple injury quite complex. Because many cuts happen while the fingers are bent, the cut
ends of the tendon move even further apart as the fingers are straightened. A tendon that has
not been cut completely through may still allow the finger to bend, but cause pain or catching
and may rupture. When both tendons are cut completely through, the finger joints cannot
bend on their own.

5. Tendon Healing: Once the two cut ends of the tendon have been sewed together, the tendon
takes 21 days to heal. However, during this period the injured area can either be protected
form movement or started on a very specific limited movement program. If unprotected and
finger motion begins too soon, the tendon repair is likely to pull apart. After four to six weeks,
the fingers allowed to move slowly and without resistance. If it is hard to bend the finger using
its own muscle power, it could mean that the repaired tendon has pulled apart or is bogged
down in scar tissue. Therapy will also address loosening of any troublesome scarring.

Treatment: The injured area is protected using a Modified Kleinert dynamic flexion splint which
positions the hand in static flexion and passively flexes the MCP and IP’s while permitting
limited active extension of the MCP and IP’s.. Other goals of the program are to promote
wound healing, edema control, prevention of the newly repair tendon from rupturing and
promoting tendon glide, prevention of contracture at the IP joint, maintain maximum joint
mobility of all joints, and improve appearance of the hand. Contra-indications: No active
flexion of all digits until approximately week 5 post injury. If a program of controlled, limited
motion is selected as therapy for the first three or four weeks after surgery. The tendon repair
can pull apart if the hand is used too soon or if therapy guidelines are not followed.

6. Extensor Tendon Injuries:

Extensor tendons located on the back of your hards allow you to straighten your fingers and
thumb. These tendons are attached to muscles in the forearm. Being on the top of the hand

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extensor tendons are directly under the skin and directly on top of bone which means they can
be easily injured even by a minor cut.

Treatment: To treat an extensor tendon injury the reverse Kleinert dynamic splint is
constructed which basically is the opposite splint than that used for the flexor tendon injuries.
This splint places the wrist in a static extension and passively extends the MCP and IP’s of the
affected fingers while permitting limited MCP flexion. (Wrist extended 30 - 40 degrees, MCP’s
flexed 30 - 40degrees, IP’s extended) Splints stop the healing ends of the tendons from pulling
apart and should be worn at all times to make sure the finger stays straight until the tendon is
fully healed.

7. Common Extensor tendon injuries:

a) Mallet Finger: droop of the DIP joint where an extensor tendon has been cut or separated
from the bone, which results in a fingertip that cannot be straightened. The splint for this injury
should keep the fingertip straight until the tendon is healed, which may take 4 - 8 weeks or
longer in some patients.

b) Boutonniere deformity: when the middle joint of a finger bends down or flexes from a cut of
tear in the extensor tendon injury. Treatment involves splinting the middle joint in a straight
position until the injured tendon heals

c) Lacerations on the back of the hand that go through the extensor tendon can cause difficulty
in straightening the finger at the large joint where the fingers join the hand. These injuries are
usually treated by stitching the tendon ends together.

8. Dupuytren’s Disease:

This is an abnormal thickening of the fascia (the tissue between the skin and tendons in the
palm) that may limit movement of one or more fingers. In some patients a cord forms beneath
the skin that stretches from palm into the fingers. The cord can cause the fingers to bend into
the palm so they cannot fully straighten. Sometimes, the disease will cause thickening over the
knuckles of the finger. It can also occur in the soles of the feet, the disease is usually painless

The cause of dupuytren’s is unknown and there is no permanent cure. Dupuytren’s mostly
affects white people of European descent and is more common in men than in women.

Symptoms: the disease occurs slowly. It is usually noticed as a small lump or pit in the palm.
This tends to occur near the crease of the hand that is closest to the base of the ring and little
finger. The disease is usually noticed when the palm cannot be placed flat on an even surface,

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such as table tops. Drawing of the fingers into the hand can occur because of contracture of the
fascia near the joints in the finger. In severe cases, drawing of the fingers into the palm
interferes in everyday living, like washing hands, wearing gloves and putting hands in pockets.

Treatment: There is no cure for dupuytren’s. Surgery can relieve the bending of the fingers into
the palm, but the condition can return with time. The goal of surgery for Dupuytren’s disease is
to restore the use of the fingers. A splint can be made after the surgery to help keep fingers
straight, night extension splints are made and may be worn from the day after surgery to
months following full extension of the affected finger(s) to ensure maximum healing and
function. Additional modalities used include: paraffin wax treatments, strengthening exercises,
hydrotherapy and ultrasound.

9. Lateral Epicondylitis:

Commonly known as tennis elbow is an inflammation of the tendon fibres that attach the
forearm extensor muscles to the outside of the elbow. These muscles lift the wrist and hand.
Pain may be felt where these fibres attach to the bone on the outside of the elbow or along the
muscles of the forearm. Pain is usually more noticeable during or after stressful use of the arm.
In severe cases lifting and grasping even light things may be painful. Medial epicondylitis is a
similar condition that occurs on the inside of the elbow.

Symptoms: the area of pain is usually found near the bone on the outer side of the elbow
known as the lateral epicondyle. This area is usually tender when touched and may be
uncomfortable when gripping.

Treatment: Stopping or limiting activities that cause the pain, such as heavy lifting with the
palm face down. Sometimes a band wrapped around the forearm near the elbow is used to
protect the injured muscles as they heal. In some cases the wearing of a wrist splint will be
recommended for the same purpose. Anti-inflammatory meds can be given by mouth and in
severe long lasting cases a medication can be injected into the area may relieve the discomfort.
Exercise such as wrist curls with a soup can and squeezing a rubber ball can be recommended
to stretch and strengthen the muscles to help prevent the condition from returning. Other
treatment ideas include using an ice pack on the elbow three times a day for 15 minutes in the
early painful stages, and stretching the inflamed area will help prevent any scar tissue that
develops with inflammation.

10. Hand Fractures:

The hand skeleton is made up of many bones that form its supporting framework. This frame
acts as a point of attachment for the muscles that make the wrist and fingers move. A fracture

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occurs when force is applied to a bone that is enough to break it. When this happens, there is
pain, swelling, and decreased use of the injured part. Many people think that a fracture is
different from a break, but they are the same. Fractures may be simple with the bone pieces
aligned and stable. Other fractures are unstable and the bone tends to displace or shift.
Comminuted fractures (shattered bones) usually occur from a high energy force and are often
unstable. An open (compound) fracture occurs when a bone fragment breaks through the skin.
Because of the close relationship of bones to ligaments and tendons, the heal may be stiff and
weak after the fracture heals. Fractures that involve joint surfaces may lead to early arthritis in
those involved joints.

Treatment: A splint can be used for fractures that are not displaced or to protect a fracture that
has been set. Some displaced fractures may be set with pins or wires without making an
incision which is cause closed reduction internal fixation. Other fractures need surgery to set
the bones, once the bones are set, they are held together with pins, plates, or screws.
Fractures that have been set may be held in place by an “external fixator” a set of metal bars
outside the body attached to pins which are fixed to the bone above and below the fracture
site until the break heals.

11. Nerve Injuries:

Motor nerves carry messages from the brain to muscles to make the body move. Sensory
nerves carry messages to the brain from different parts of the body to signal pain, pressure, and
temperature. Nerves are fragile and can be damaged by pressure, stretching, or cutting. Injury
to a nerve can stop signals to and from the brain causing the muscles not to work right, and you
may lose feeling in the injured areas. A nerve is like an electrical cable wrapped in insulation.
When nerve fibres are cut, the end of the fibre farthest from the brain dies, while the insulation
stays healthy. The end that is closest to the brain does not die, and after some time may begin
to heal. If the insulation was cut, new fibres may grow down the empty cover of the tissue until
reaching a muscle or sensory receptor. If the nerve and the insulation have been cut and the
nerve is not fixed, the growing nerve fibres may grow into a ball at the end of the cut, forming a
nerve scar or neuroma. This can be painful and cause an electrical feeling when touched.

Treatment: First to fix a cut nerve, the insulation around both ends of the nerve are sewn
together. The goal in fixing the nerve is to save the cover so that new fibres may heal and work
again. Once the nerve cover is fixed, the nerve generally begins to heal three or four weeks
after the injury. Nerves usually grow one inch every month depending on the patients age and
other factors. This means that with an injury to a nerve in the arm above the finger tips, it may
take up to a year before feeling returns to the fingertips. The feeling of pins and needles is

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common during the recovery process. As on OT splints may need to be constructed and an
exercise program must be set up in order to keep joints flexible. If joints become stiff, they will
not work even after the muscles begin to work again. When a sensory nerve has been injured,
the patient must be extra careful not to burn or cut fingers since there is no feeling in the
affected area.

12. Reflex Sympathetic Dystrophy (aka Complex Regional Pain Syndrome)

TYPE 1: occurs after a event. Pain that is not limited to the territory of a single peripheral nerve
occurs spontaneously and is disproportionate to the original hand injury. There is edema, with
abnormal skin colour and stiffness.

TYPE 2: is the same as type one, only it occurs after a nerve injury.

Secondary symptoms for both types are sudomotor changes (sweating), temperature changes,
trophic changes, vasomotor instability, thickening of the palmar fascia and goose bumps or hair
standing on ends.)

Treatment: Most important therapy guideline is no PROM or painful treatment. The first thing
is to control pain. This can be in the form of meds, sympathetic nerve blocks and modalities
such as TENS. Water aerobics and functional activities are excellent ways to provide active
movement incorporating reciprocal motion. Stress loading exercises (“scrubbing the floor” -
literally down on all fours, 3 times a day and carrying a heavy briefcase.) The weight should be
light and tolerable.

Avoid PROM or other therapy until the pain and swelling begin to subside, and then monitor
responses closely. Incorporate traditional hand therapy, including splinting and other
nonaggrevating modalities with edema control, joint ROM, tendon gliding exercises. It is better
to perform gentle pain free active exercises frequently for short periods then fewer and longer
sessions. Light massage and active exercise help to interrupt the pain cycle.

Basic Interventions for common problems:

1. Edema Control:

 elevate the swollen hand or arm

 active exercises
 hot and cold contrast baths
 compression garments (should not be too tight)
 retrograde massage

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2. Scar Management:

 Compression (isotoner gloves, tubigrip, or coban wrap)

 Silicone gel helps promote scar maturation
 friction massage

3. Tendon Gliding:

Tendon gliding exercises (hand straight in extension, flex the IP’s, make a fist, flex at the MCP’s,
flex MCP’s, and IP’s with thumb in extension). Tendon guiding exercises promote digital and
joint motions, and are the mainstay of many home exercises programs.

4. Exercise Programs:

Blocking Exercises - blocking the IP joint helps to isolate and exercise MP flexion and extension.
Blocking the MP’s in a flex position promotes extrinsic extensor stretch. A PIP block encourages
DIP isolated flexion and flexor digitorum profundus excursion.

Place and hold exercises: are effective for increasing ROM when there is more PROM then
AROM. The therapist passively places the hand in a position (e/g fist) and then releases the
assisting hand while the patient tries to sustain the position in a pain free way

5. Splinting:

Static Splint: no moving parts, used primarily for support, stabilization, protection or
immobilization

Serial Static Splinting: Can be used to lengthen tissues and regain ROM by placing the tissues in
an elongated position for prolonged periods of time. With this process, splints are remolded as
ROM increases.

When using static splints remember that immobilization causes unwanted effects such as
atrophy, and stiffness so the static splint should never be used longer than physiologically
required and should never unnecessarily include joints other than those being treated.

Static progressive Splints: use nondynamic components, such as velcro, hinges, screws or
turnbuckles to create a mobilizing force.

Dynamic Splints: Use moving parts to permit, control, or restore movement. They are primarily
used to apply an intermittent, gentle force with the goal of lengthening tissues to restore
motion. Force may be generated by springs, spring wires, rubber bands, or elastic cords. When

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using dynamic splinting must remember that force must be gentle and applied over a long
period of time (100 - 300 g of force), and the line of pull must be at a 90 degree angle to the
segment you are trying to mobilize. To ensure this, the forces are directed by an outrigger, a
structure extending outward from the splint.

Huntington’s Disease

Definition: A genetically inherited fatal, degenerative neurological disorder. Results in

deterioration of the corpus striatum, which is involved in motor control.

Presentation: Impacts voluntary and involuntary movements and deterioration of cognitive and
behavioural abilities. Typically presents between the ages of 30 and 40 and clients live for 15 to
20 years with the disease.

Early symptoms: Alterations in behaviour (irritability or depression), cognitive functioning

(attention and forgetfulness) and choreiform movements in the hands (rapid, jerky, involuntary
movements)

Chorea: Rapid, involuntary, irregular movements. Exacerbated during stressful conditions.

Absent when sleeping. Progresses with disease throughout the entire body, wide-based gait,
difficulties walking on uneven terrain.

Cognitive and emotional abilities progressively deteriorate. Difficulty completing tasks in

unfamiliar environments, difficulty with calculations, performance of sequential tasks and
memory.

Dysarthria: Later progression, difficulty speaking due to limited control of facial and tongue
muscles required for speech.

Dysphagia: High risk for choking.

Suicidal risk is high.

Prognosis: clients end up in LTC unable to talk or walk.

Calorie Intake: Because of chorea, often burn 3000 to 5000 calories per day

Assessments:

1. Cognition: memory, concentration, attention, sequencing.

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2. Affect: Beck Depression Scale

3. Task Analysis: particularly during early stages when client may be employed.

4. Work Site Evaluation: modify tasks if needed.

5. Capacity: consider clients ability to handle financial matters.

Interventions:

 Memory Strategies: Daily routine, checklists, task analysis, breaking down steps.
 Employment: modify work environment.
 Timers: to remind to perform tasks.
 Environmental Modifications: decrease distractions when memory and concentration is
impacted.
 Social Contacts: encourage maintenance of social contacts and activities.
 Community Support: loss of income is a significant issue and ability to drive
 Fine Motor Activities
 Equipment: built-up cooking and eating utensils, unbreakable dishes, shower bench,
grab bars, high-backed seats with arms and remove clutter.
 Exercise: home exercise program for strength and flexibility.
 Leisure
 Mobility: may require walker or wheelchair. May have an easier time with foot
propelling than with arms.
 Diet: require high calorie, small meals throughout the day.
 Feeding: dysphasia requires positioning, oral motor exercises and changes in diet
consistency.
 Splinting: during later stage to prevent contractures.

Informed Consent Guidelines

College of Occupational Therapists of Ontario. (1996, September). A Guide to the Health Care
Consent and Substitute Decisions Legislation for Occupational Therapists.

Definition: Specific to treatment being proposed Voluntary not obtained through

misrepresentation or fraud informed: person has information reasonable person in same

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circumstances would require to make a decision & person receives responses to requests for
additional information related to treatment decision (includes information re: nature of
treatment; expected benefits, risks, side effects; alternative courses of action; likely
consequences of not having treatment) person is capable of giving consent (see below re:
assessment of capacity).

OT role under HCCA: “The practitioner who is proposing the treatment is responsible for
obtaining informed consent to the treatment.” (COTO, 1996, p. 6). For admission to a care
facility or personal assistance services, person evaluating capacity may be person proposing, or
someone designated as an "evaluator" by the organization. OT’s are recognized under the HCCA
as eligible evaluators. When practitioner proposing treatment believes person is not capable of
making decision, consent must be obtained by appropriate substitute decision-maker (SDM
must be at least 16 unless parent of the client):

 official court guardian

 attorney for personal care
 representative appointed by Consent & Capacity Board
 spouse or partner
 child if 16 or over OR custodial parent
 parent who only has right of access
 brother or sister
 other relative

Assessing capacity under HCCA: Capacity is the ability to understand the information that is
relevant to making a decision concerning the treatment appreciate the reasonable foreseeable
consequences of a decision or lack of decision. (In)capacity is treatment specific and may
change over time.

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Steps

1 When to assess Person presumed capable unless in professional judgment there is some reason to
believe otherwise – for example (but not limited to):

evidence of confused or delusional thinking

inability to make a settled choice

severe pain or acute fear or anxiety

severe depression

impairment by alcohol or drugs

any other observations that give rise to concern about behaviour.

Factors such as diagnosis, disability, age are taken into account in assessment but can't
be the basis of a presumption of incapacity.

2 Understanding If you think the person may not be capable of giving consent, assess whether person
the information understands:

the condition for which the treatment is proposed; and

the nature of the proposed treatment, and

the risks and benefits of the treatment, and

the alternative to the treatment, including the alternative of not having the treatment.

3 Appreciating the If person is able to understand the information, must also assess whether able to
consequences appreciate reasonable foreseeable consequences of decision:

able to acknowledge that the condition may affect him/her, and

able to assess how treatments or lack of treatments discussed by health professional

could affect person's life or quality of life, and

person's choice is not substantially based on a delusional belief.

If person cannot appreciate any one of these factors, person is not capable of giving
consent.

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 L

Learning Disabilities

Definition: Inability to acquire, retain or generalize specific skills or information due to deficits
in attention, memory, reasoning or producing responses. Does not imply deficient cognitive
abilities.

Presentation:

 Dyslexia: impacts reading

 Dyscalculia: arithmetic
 Dysphasia, dysnomia: difficulties with expressive language
 Dysgraphia: difficulties with written expression and handwriting
 Difficulties with nonverbal communication

Assessments:

1. Miller Assessment for Preschoolers

2. 2 yrs 7 mo – 5 yrs 8 mo

3. Domain: foundations, coordination, verbal, nonverbal, complex tasks

4. Bruinicks-Oseretsky Test of Motor Proficiency: measures gross and fine motor in kids 4 to 15
y.o.

5. Peabody Developmental Motor Scale (PDMS): evaluate gross and fine motor skills for 0 to 6
y.o. Looks at: reflexes, stationary (body control/posture), locomotion, object manipulation,
grasping and visual motor.

6. Motor-Free Visual Perceptual Test: assess visual-perception abilities 4 to 70 y.o.

7. Visual Motor Integration: assess for learning difficulties be examining coordination of visual
perception and finger-hand movements

8. School Functional Assessment: looks at barriers in student’s environment, looks at level of

participation, kindergarten to grade 6

Intervention:

 Self-Care: use routine boards to list tasks, provide checklists, use timers and picture
symbols.

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  Productivity: organizational skills, use calendars, organizers in notebooks, computers (if
easier), photocopy notes
 Leisure: encourage leisure activities to provide sense of mastery.
 Physical: encourage body management (balance, manipulation, reflexes, improve
muscle tone, gross motor skill, fine motor skills
 Cognitive: organize, plan, sequence actions: use prompts, visual cues, reward for timely
activities, memory skills
 Psychosocial: improve self-esteem and confidence, emotional control, social interaction
and communication
 Environment: provide info to teachers and parents

Low Back Pain

Definition: Pain caused by sprain, strain or tear of a soft tissue (muscle, tendon, ligament) pain
may radiate from other areas like mid or upper back symptoms may include tingling or burning
sensation, a dull aching, or sharp pain; may experience weakness in legs or feet; muscle spasms

Common Causes: May not be one event; doing multiple tasks with poor positioning over
extended period of time (eg. standing, sitting, or lifting) repetitive motions at work, lifting heavy
object, move in sudden abrupt manner ie. motor vehicle accident, fall, osteoporosis, ruptured
or herniated disk, fibromyalgia

Timeline: May be acute (less than one month) or chronic (longer than three months) typical
injuries approx. 3 months recovery (when participating in active rehabilitation)

Potential OPIs: Many potential OPIs because any activities which include bending, lifting, or
remaining in a position for an extended period of time (standing, sitting) will exacerbate the
pain. Examples:

 Self-care: washing hard to reach places of body; dressing lower extremity

 Home maintenance: floor care, dishwashing, laundry
 Productivity: sitting at desk and computer; heavy labour
 Leisure: watching a movie; jogging

Assessment:

OT responsible for assessment of occupational performance. OT may conduct in-home

assessment, ergonomic assessment, job site analysis, physical demands analysis (PDA) and

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functional abilities evaluation (FAE). Assessment involves interview, observation of client
completing tasks, and physical assessment (functional range of motion and strength)

Biomechanical Frame of Reference: (4 Assumptions)

 Purposeful activities can be used to treat loss of ROM, strength and endurance
 After ROM, strength and endurance are regained, individual regains function
 Rest and stress (the body must rest to heal and peripheral structures must be stressed
to regain ROM, strength and endurance)
 This frame of reference best suited for individuals with intact CNS
 Adaptive (Compensatory) Approach: Facilitates function through environmental
adaptation (prescription of adaptive equipment; assistance from a caregiver)

General Interventions:

1. Energy conservation: provide client with education on energy conservation techniques (e.g.
pacing; sit vs. standing; long handled reacher; avoid static positions for long period of time)

2. Work Simplification: provide education to client

3. Proper body mechanics: provide education to client on maintaining neutral alignment of

spine and extremities while performing tasks. Keep body close to the item or task to prevent
unnecessary slouching or bending and to decrease stress to back. Use a stool vs. bending. Lift
with legs, not back. Place pillow between knees when sleeping on side or under knees when
sleeping on back to decrease stress to back and promote proper spinal alignment. Keep feet on
solid base of support so that knees are at 90-100°, with knees higher than your hips. Pain
control techniques: hot bath, icing 10-15 minutes, anti-inflammatory meds as recommended by
physician, reduction of activity initially with gradual return to pre-accident activity, light
stretches to promote circulation and healing. Promote participation in an active rehabilitation
program (may include the following health professionals: physiotherapist, kinesiologist,
physician, chiropractor and massage therapist).

Home Intervention: Provide the above education to client as it applies to personal care, home
maintenance and yard maintenance tasks. Examples of assistive devices to facilitate return to
function and decrease of back pain: Long handled cleaning device (decreases need to bend and
exert forces through arms, thus enabling client to perform bathroom cleaning). Swiffer/floor
cleaning device (educate client to move with the device, rather than using back and forth
movements with the arms; enables client to efficiently clean floor with reduced pain). Long
handled dustpan and broom (reduces need to bend to pick up dirt). Reacher. Long handled bath

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sponge (enables client to safely and independently wash difficult to reach areas of body). Light-
weight vacuum (enables client to safely and independently vacuum, due to decreased weight to
set up, use on stairs, and to push across carpet). Lumbar roll (provide support to back and
enable prolonged sitting).

Work Intervention: Ergonomic assessment and intervention to workstation (promoting proper

body mechanics through supportive seating, proper placement of frequently used items, height
adjustment to work station). Provide the education described in “general interventions”
section. Coordinate with employer graduated return to work with modified duties or to new
position. Work hardening.

*Motor Unit Dysfunction

Definition: The motor unit includes the cell body of the motor neuron in the anterior horn
(which mediate all voluntary movements and reflexes), axon of the motor neuron traveling via
spinal and peripheral nerves to the muscle, neuromuscular junction and the muscle fibers
innervated by the neuron.

Diseases cause muscle weakness and atrophy of the skeletal muscle. Origin may be:

 neurogenic = the ‘lower motor neuron disorders’ (affecting cell bodies), and peripheral
neuropathies (affecting peripheral nerves)
 myopathic = affect the neuromuscular junction of the muscle itself

Lesions can result from nerve root compression, trauma, toxins, infections, vascular disorders,
degenerative diseases of the CNS, or congenital deformities.

Assessment: Largely depends on type of motor unit disorder. Global assessment may include
feeding, joint ROM (particularly if muscle imbalances exist), pain, muscle tenderness/strength,
sensation, and/or functional independence. Watch for primitive protective sensations,
tingling/numbness, muscle tone changes, ability to sweat. Consider prognosis of condition (i.e.
is the condition progressive degenerative or is the patient likely to recover with few effects?).

Intervention: Primarily assist the person regain maximal functional independence. In

progressive degenerative cases assist in maximizing comfort, minimizing pain, and providing
activity that is intellectually and psychologically stimulating. Splints may be used to protect or
immobilize extremities (particularly with peripheral nerve injuries).

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Specific Motor Dysfuntions:

1. Poliomyelitis:

 Contagious viral disease affecting anterior horn cells of gray matter of spinal cord and
motor nuclei of the brainstem; muscle belly is very tender and painful
 Incubation period of 1-3 weeks (recovery depends on # of nerve cells destroyed)
 Results in flaccid paralysis, primarily of lower extremity, muscles of respiration,
swallowing (upper extremity can also be affected)
 Medical treatment in acute phase is bed rest, positioning, application of warm packs to
reduce pain and promote relaxation
 Therapist can help patient make use of remaining muscle function as damage to
anterior horn cells is permanent
 PROGNOSIS: after acute medical problem has subsided, maximal recovery in first 8mo,
may last 2 years

2. Postpolio Syndrome:

 Advanced weakness onset later in life in people who had polio early in life
 Cause not fully understood (motor unit dysfunction is one theory; another is
musculoskeletal overuse and disuse)
 May present with contractures; benefits of exercise controversial
 PROGNOSIS: biggest long term concern is fatigue (disproportionate to demands of
activity)

3. Guillan Barre Syndrome:

 Acute inflammatory condition involving spinal nerve roots, peripheral nerves and in
some case cranial nerves
 Follows a viral illness, immunization, or surgery
 Produces a hypersensitive response resulting in patchy demyelination of lower motor
neuron pathways
 Characterized by rapid onset, initially no fever but only pain and tenderness of muscles,
generalized weakness and decreased tendon reflexes – later produces motor weakness
or paralysis, sensory loss and muscle atrophy
 PROGNOSIS: in most cases patients recover in a few weeks with few residual effects

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4. Peripheral Nerve Injuries:

 Atrophy occurs and deep tendon reflexes are absent or depressed, faciculations (minute
muscle contractions) may be seen on the surface of the skin
 Ability to sweat above the denervated skin surface is lost; may experience parathesias
(tingling, numbness, burning, or pain especially at night)
 ‘neuropraxia’ is a nerve lesion usually caused by orthopedic injuries
 ‘neurotmesis’ is a complete severance of the nerve
 ‘axonotmesis’ is a disruption of nerve fibres causing peripheral degeneration
 Splinting can protect the site of injury; manual massage with elevated extremity can
reduce edema
 PROGNOSIS: nerve regeneration begins about 1mo following injury, indicated by skin
appearance, primitive protective sensations, scattered points of sweating, discriminative
sensations, muscle tone, voluntary muscle function

5. Volkmann’s Contracture:

 After fracturing a humerus and immobilization, the patient’s hand may be cold, clammy,
with smooth glossy appearance; if radial pulse cannot be detected call the physician; if
ischemia lasts for 6 hours then contracture will follow

6. Brachial plexus injury: C4-T1

 a) ERB’S PALSY: lesions to 5th and 6th brachial plexus roots. Paralysis and atrophy of
deltoid, brachialis, biceps, brachoradialis. Clinically the arm hangs limp, hand rotates
inward and functional hand movement is limited.
 b) KULMPE’S PALSY: lesions to C8 and T1. Paralysis to distal musculature of the wrist
flexors and intrinsic muscles of hand.
 c) Manifestations of peripheral nerve lesions:

C5-C7 Winged Scapula

C5-C6 Loss of scapular adduction and

elevation

Weakened lateral rotation of humerus

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 Weakened medial rotation of humerus

C7-C8 Loss of arm adduction and extension

C6-C8, T1 Wrist drop, extensor paralysis (radial

nerve)

Ape hand deformity

Weakened Grip

Thenar atrophy

Loss of thumb adduction (median)

C5-6 Loss of arm abduction

Weakened lateral rotation of humerus

Loss of forearm flexion and supination

C8, T1 Claw hand deformity

Loss of thumb adduction (ulnar nerve)

7. Myasthenia Gravis:

 Disease of the neuromuscular junction

 Caused by an autoimmune response in which antibodies are produced against nicotine
acetylcholine receptors and interfere with synaptic transmission (skeletal muscle
weakness due to neurotransmitter defectiveness)
 All ages but primarily younger women and older men
 PROGNOSIS: usually progresses and patients become confined to bed with severe,
permanent paralysis
 Therapist can provide gentle, non-resistive exercises to stimulate the patient without
causing fatigue

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8. Duchenne’s Muscular Dystrophy:

 Inherited as x-linked recessive trait; is one of many myopathic disorders that all have
progressive degeneration of muscle fibers while neuronal innervation remains intact
(decline in muscle function cannot be prevented)
 Diagnosed between 18-36mo, calf muscles hypertrophic due to infiltration of fat cells
 PROGNOSIS: death usually occurs by age 30

Multiple Sclerosis

Definition: Slowly progressive neurological disease that damages the myelin sheath in the CNS.
Causes inflammation & often destroys the myelin in patches. The severity of MS, progression
and specific symptoms cannot be predicted at the time of diagnosis.

Onset usually occurs between ages 20-40; Prevalence: 60-100 people per 100,000; Women
develop MS almost twice as often as men do.

Specific cause Unknown..Suspected to be result of combination of environmental & genetic

factors. Most researchers believe that MS is an autoimmune disease - the body's immune
system malfunctions & starts attacking the myelin. There is some evidence that MS may be
triggered by a common virus & that certain people are more susceptible because of genetic
factors.

The main types or patterns of MS (the first 3 being the most typical):

 relapsing-remitting MS - characterized by clearly defined attacks (relapses) followed by

partial or complete recovery (remissions); most common form (70% at the time of
diagnosis)
 primary-progressive MS - relatively rare (10 to 15% at time of diagnosis), people with
this type of MS have a nearly continuous worsening of MS from the beginning with no
clear relapses or remissions
 secondary-progressive - about half of people with relapsing-remitting MS start to
worsen within 10 years of diagnosis, with the possibility of increasing levels of disability
 progressive-relapsing - relatively rare, combines attacks with steady worsening & no
remissions
 benign MS - few attacks with long periods of remission & little disability after 15 years;
about 20 - 25% of people who were diagnosed originally with relapsing-remitting MS
have this type

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  malignant MS - rapidly progressive disability within five years of diagnosis; quite rare

Presentation:

 Signs & symptoms are dependant on the part or parts of the CNS that is affected. The
damaged parts of myelin are often called "lesions" or "plaques". The result may be the
wide variety of MS symptoms, 3 categories:
o primary (directly related to the demyelination): transient fatigue, double vision,
optic neuritis, paresthesia, motor weakness, ataxia, unsteady gait, bowel &
bladder dysfunction, pain, decreased cognition, spasticity, neuralgia, dysarthria,
dysphagia
o secondary (complications of the primary symptoms): contractures, urinary tract
infection, decubitus ulcers, pain, cognitive impairments
o tertiary (result from reactions to the primary & secondary symptoms):
emotional, social, & vocational impact of the disease on the person, family &
community

Assessments:

Focus on assessing the current level of functioning in:

 All occupational areas (self-care, productivity & leisure)

 Performance components
 Physical – strength, endurance/fatigue, tone, coordination, dexterity, hand functions,
balance/postural control, Active ROM/Passive ROM/Functional ROM,
mobility/ambulation, sensory registration/processing, visual perception
 Cognitive – attention, concentration, memory, learning, following directions, problem-
solving, decision making
 Affective – Values, beliefs, self-concept, coping skills, communication skills
 Environment – home & work barriers as well as modifications
 Examples of standardized assessments to use: Canadian Occupational Performance
Measure (COPM); Functional Independence Measure (FIM); Mini Mental State
Examination (MMSE); Hand Grip Strength; Qual-OT (quality of life assessment tool);
Fatigue Impact Scale (FIS); Modified Ashworth Scale (muscle tone); Berg Balance Test;
OSOT Perceptual Evaluation; Motor-Free Visual Perception Test

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Interventions:

Models of treatment include: remedial, compensatory, maintenance, prevention, &

environmental adaptation.

 Physical: Key is to remain active. Use of an exercise program & education on good body
mechanics can often be helpful to improve strength and overall conditioning. An OT may
teach various techniques to assist with management of poor upper extremity weakness
and/or coordination. Fatigue management skills (e.g., pacing, work simplification) are
taught to help with energy conservation in order to enjoy activities. Splints, stretching &
ROM exercises to prevent contractures. Adaptive equipment is provided as a
compensatory technique when people have difficulty performing their activities of daily
living. Providing instruction on safe transfers. Seating & positioning interventions where
various equipment is tried & recommended with follow up for positioning and comfort.
 Cognitive: Remediation & compensatory techniques are used to treat cognitive
impairments. E.g., remediation: use computer programs &/or paper tasks to help
increase their attention, memory etc. E.g., compensation techniques: writing things
down or using timers to help people recall information. For people with severe cognitive
impairment the family can be educated about the impairment & adaptation in the home
can be made or greater supervision to keep the individual safe. Other areas to educate
on include: time-management skills, planning ahead, safety, etc.
 Affective: Role changes, self esteem building activities & coping skills are used to help
people adjust to this disease process & the changing conditions they may experience.
Group interactions are helpful as the individuals can learn from one another & feel as if
they are not alone in their experience. Other areas include: stress-management training,
setting goals, increasing feelings of control in one’s life, encourage family cooperation &
support, etc.
 Environment: Recommendations for the environment to increase safety & energy
conservation. Education for client & family on MS & how it affects performance.
Education on support in community & explore services such as public transport (if
unable to continue driving). Education on fatigue management & on function of
assistive devices etc.

Muscular Dystrophy

Definition: Neuromuscular disorder, changes internal surface of the muscle cells and results in
progressive degeneration, weakness, deformity and death

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  Limb-Girdle Muscular Dystrophy: initially affects pelvis and shoulder girdle, onset in first
to third decade of life
 Facioscapulohumeral Muscular Dystrophy: early adolescence, primarily in the face,
upper arms and scapular region. Decreased ability to raise arms above head, mask like
face
 Duchenne’s Muscular Dystrophy: most common type. Deficiency in production of
dystrophin, X-linked, only affects boys, dystrophin in plasma membrane of muscle
fibres, muscles degenerate. Diagnosed typically between 2 and 6 y.o.

Presentation:

 Difficulty climbing stairs and rising from sitting or lying

 Falls and tires excessively
 Enlarged calf muscles due to fibrosis and proliferation of adipose tissue
 Starts in pelvic girdle, progresses to shoulders and then affects all muscles
 Gower’s: common sign, child uses hands to push on legs to help stand.
 Typically use wheelchair by 9 y.o.
 Eventually bed ridden, dependent in all ADLs
 Death in early 20’s as a result of respiratory complications
 Cognition: can have mild impairment that is nonprogressive and affects verbal ability.

Assessments:

 ADLs
 Play and leisure skills
 MMT, ROM, Endurance, gross and fine motor development and milestones, balance,
postural control
 Scales: self-care, mobility, cognition
 Bruinicks-Oseretsky Test of Motor Proficiency: measures gross and fine motor in kids 4
to 15 y.o.
 Peabody Developmental Motor Scale (PDMS): evaluate gross and fine motor skills for 0
to 6 y.o. Looks at: reflexes, stationary (body control/posture), locomotion, object
manipulation, grasping and visual motor.
 Motor-Free Visual Perceptual Test: assess visual-perception abilities 4 to 70 y.o.
 Miller Assessment for Preschoolers
o 2 yrs 7 mo – 5 yrs 8 mo
o Domain: foundations, coordination, verbal, nonverbal, complex tasks
 WeeFIM:

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 o 6 months – 7 years
o Measures functional independence by measuring need for assistance

Interventions:

 Stretching and ROM, strengthening of muscles and cardiovascular system, prevent

contractures (passive ROM and splinting)
 Assistive Devices: for self-care (eg. Velcro, elastic pants, zipper pulls, sock aid, etc).
 Environmental control unit for lights, telephone, TV, CD player.
 Seating
 Productivity: computer for school work
 Leisure: promote inclusion, eg. score keeper in games using technological assist
 Energy conservation: for child and family
 Psychosocial: encourage leisure activities that provide a sense of mastery. Technology
provides opportunity for control over life and environment.
 Environmental Modifications: ramps, flooring, widening door ways, bathroom
equipment
 Pressure relieving mattress

Parkinson’s Disease

Definition: An adult-onset degenerative neurological disorder. Classic symptoms: tremor,

rigidity and bradykinesia (slowed ability to start and continue movements). Deteriorates the
substantia nigra which causes a decrease in basal ganglia activity. Slowly progressive movement
disorder. Not fatal, however, degeneration of neurological structures compromises functional
performance.

Presentation:

 Impacts voluntary and involuntary movements.

 Akinesia: difficulty initiating movements.
 Bradykinesia: slowness in maintaining movements.
 Rigidity: stiffness in muscles that impedes smooth movements.
 Resting Tremor: in some clients it diminishes with activity.

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  Disturbances in gait and postural reactions. Later progression: festinating gait, short
stride length and increase in speed, appears to be shuffling. Reduced arm swing during
ambulation.
 Masked face
 Freezing: motor disturbance where the person ceases to move.
 Stooped posture: flexion at knees and hips when standing.
 Depression
 Visual Spatial perception can be compromised during later stages.
 Cognition: difficulty shifting attention, processing simultaneous information, dementia
occurs in 1/3 of people with Parkinson’s.
 Autonomic dysfunction: The autonomic nervous system regulates unconscious body
functions, including heart rate, blood pressure, temperature regulation, gastrointestinal
secretion, and metabolic and endocrine responses to stress such as the "fight or flight"
syndrome.
 Dysphagia: difficulty swallowing
 Dysarthria: difficulties with speech
 Bowel and bladder issues

Stage 1: Micrographia: early symptom resulting from hand tremor, handwriting becomes small.
Rigidity in hand when opening and closing it quickly.

Stage 2: bilateral motor symptoms (tremor and rigidity), still independent with ADLs. Stooped
posture but ambulating independently.

Stage 3: delayed righting and equilibrium reactions. Due to impaired balance, difficulty
performing tasks in standing.

Stage 4: difficulty with ADLs, but ambulating independently.

Stage 5: typically require wheelchair or in bed, dependent for ADLs.

Assessments:

1) Unified Parkinson’s Disease Rating Scale: evaluates motor skills, functional status and extent
of disability. Patient interview and observation.

2) Parkinson’s Disease Questionnaire: examines quality of life

3) Home Assessment

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4) ADLs: FIM, Assessment of Motor Process Skills (AMPS), Klein Bell

5) Functional Assessments: morning routine, kitchen tasks

6) MMT, ROM, Goniometry

7) Handwriting Sample

8) Timed movements (establish baseline)

Interventions:

 Compensatory Strategies: built up handles, written work should be done shortly after
taking medications (time management). Modified clothing fasteners, slip on shoes,
remove rugs and clutter, chairs with arms to help with standing.
 Energy Conservation: fatigue is a common symptom.
 Patient and Family Education:
 Environmental Modifications: light touch switch activation of devices can allow client to
exert control over environment during later stages.
 Task Modifications:
 Exercise Program: daily routine addressing ROM, postural flexibility (trunk extension).
 Relaxation Techniques: controlled breathing to improve relaxation and postural
alignment.
 Community Agencies: for support and assistance (decrease care giver burden).
 Music: rhythm to help initiate movement.
 Rocking Motion: to help initiate movements as akinesia becomes more involved.
 Oral Motor Exercises: for swallowing and drooling.
 Visual Cues and practice to help initiate movements.
 Motor Learning Principles

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Pediatric Conditions – Misc.

*Developmental Milestones: (Know these!!!!!!)

Age Gross Motor Fine Motor Cognition Language Social- Physical

Emotional and
Mobilit
y

Birth to 3 - Rotates head - Flexed, - Coordinates - Cries, laughs, - Shows -1

mos in supine fisted hands eye movements vocalizes parent excitement, month
responses agitation
- Head lag - Involuntary - Searches for total
release sounds - Develops flexion
- Random social smile pattern
kicking

- 1-2
mos
lifts
head 45
degrees

- 3 mos
lifts
head
45-90

- head
lag
present

- 1 mos
automa
tic
steppin
g

- 3 mos
bears
some

74 | P a g e
 weight

4 to 6 mos - Prone - Looks at - 5 to 7 second - Laughs, - Smiles, laughs -

propping hands memory babbles Extends
- Shows
- Sits - Palmar - Begins to frustration arms
unsupported grasp understand and
cause and effect - Attends to
knees
- Rolls people
- Recognizes
- Arms
familiar objects
and people
assist in
pulling
to sit

- No
head
lag

- Bears
most
weight
in
support
ed
standin
g

7 to 9 mos - Sits to play - Lateral - Inspects - Sings to music - Social games, -

pinch objects engages with Rightin
- Pulls to stand - Shouts, other children
- Bilateral - Memory for understands g
manipulatio past “no” - Stranger reactio
n anxiety ns
- Increased
attention
- Pulls
to
stand,
bears
full

75 | P a g e
 weight

10 to 12 - Cruises - Pokes with - Goal directed - Uses words - Strong - Focus

mos around index finger behaviour, with meaning, attachment on fine
furniture, may searches for understands
- Controlled motor
take a few objects simple
steps release commands activitie
s
- Stands - Holds
independently bottle
- Stands
with
one
hand
holding
on

13 to 15 - Crawls up - Scribbles - Copies actions - Names objects Increased

mos and down by functions, exploration
stairs - Releases to - Recognizes gestures for
throw similarities and emphasis Secure in
- 2-footed differences attachment
jump

- Walks
backwards

16 to 18 - Stands on - Throw ball - Mental - Repeats and - Secure in

mos one foot problem solving mimics attachment
- Copy
- Kicks ball vertical - Understands
strokes “where”
- Stiff-legged questions
run
- Names
common
objects and
pictures

18 to 24 - Walk on a - Snips with - Mental - Attends to - Conflict

mos line scissors problem solving stories between
independence
- Ride tricycle - Circular - Deferred - Understands

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 - Throw with strokes imitation common and attachment
direction prepositions
- Separation
- 2 to 3 word anxiety
sentences, talks
on phone - Parallel play

2 to 3 years - Walk on tip - Hand - Symbolic play - Uses personal

toes preference pronouns
- Knows body
- Stairs without - Trace parts - Sings from
support simple memory
shapes - Sorts and
- Catch a ball names colours - Uses plural,
- Undo large adjectives, and
buttons - Knows name verbs, 250 word
and age vocabulary
- Understands
Big, Little, Over,
On, Under

3 to 4 years Hops forward Static tripod Orders objects Fluent speech

by size
Alternates Cuts on Tells stories
steps straight line Counts 10
objects 4 to 5 word
Skips Draws stick sentence
person
400 word
Tries to vocabulary
colour in
lines

4 to 5 years Walk on Do up Completes Describes in

balance beam buttons simple puzzles detail

Somersault Prints name Counts to 30 Asks for word

meaning
Understands
more or less Rhymes

5 to 8 years Jumps rope Dynamic Logical Understands Compares self

tripod reasoning syllables to others
Push ups and

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 sit ups Ties shoes Complex cause Tells original Cooperative
and effect stories play
Rides bike Prints
accurately Mostly same
sex friends

8 to 12 Moving to Basic grammar Increased sex

years abstract of adulthood role
reasoning differentiation
Expanding
Less egocentric vocab Sensitive to
criticism
Emphasis shifts
to reading Experiment
development with group
roles

Test limits

Adolescenc Considers Search for self

e multiple identity
possibilities
Sexual relations
Hypothesize
Develop
Plan and autonomy
research ideas

Failure to Thrive (FTT)

Definition: Infants whose weight is consistently below the 3rd percentile for chronologic age,
who show progressive decrease in weight to below the 3rd percentile, who weigh less than 80%
of ideal weight for height and age or who show a decrease in expected rate of growth based on
the child's previously defined growth curve

Organic FTT: growth failure due to an acute or chronic disorder known to interfere with normal
nutrient intake, absorption, metabolism, or excretion or to result in increased energy
requirements to sustain or promote growth

Non-organic FTT: refers to growth failure due to environmental neglect (eg, lack of food) or
stimulus deprivation in the absence of a physiologic disorder that accounts for the growth
failure

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Presentation: Comorbidities: impairments in major organ systems; disorders such as Down’s
Syndrome, cystic fibrosis, diabetes mellitus, hyperthyroidism, GERD; cleft lip or palate

Psychosocial Factors: difficult infant temperament and behaviour, depression secondary to

stimulus deprivation or environmental factors (e.g. disturbances in parent-child interaction,
inadequate caregiving, financial difficulties within the family, inadequate supply of breast milk)

Assessments:

 Diagnosis requires a coordinated team approach to assess information from a growth

chart, dietary history of the child, assessment of the child’s elimination pattern, medical
history, family & social history.
 Developmental assessment: Peabody Developmental Motor Scale (PDMS): evaluate
gross and fine motor skills for 0 to 6 y.o. Looks at: reflexes, stationary (body
control/posture), locomotion, object manipulation, grasping and visual motor.
 Feeding Evaluation: oral motor and swallowing assessment and behavioural feeding
assessment.
 Environmental evaluation assessing infant interactions during play and feeding with
caregiver and non-family members

Intervention:

 Neurodevelopmental model
 Sensory Integration
 Improve oral-motor feeding skills (reduce oral-tactile hypersensitivity, promote
swallowing pattern)
 Facilitate attainment of age-appropriate developmental skills (increase gross/fine motor
skills, improve attention & memory skills)
 Facilitate age-appropriate self-care & play opportunities to help decrease signs of
apathy, withdrawal and irritability & enhance child’s self-efficacy
 Promote a positive environment by providing caregiver education in the following
areas:, normal growth & development for infants & young children, adequate nutrition,
strategies to enhance parent-child interaction – establishing eye contact, singing or
gesturing to the child, touching or holding the child, appropriate play activities,
importance of ensuring that the child is not over stimulated or fatigued

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Feeding

Definition: Children with different disabilities may have difficulties with feeding: heart defects
may lack energy to effectively suck, cleft palate requires strategies for food ingestion, motor
control difficulties such as CP can experience difficulties with chewing and utensil use,
secondary problems related to parents’ method of presenting food.

Presentation:

 Oral Sensitivity: children may experience hypersensitivity in and around the mouth;
common with autism, PDD, CP and sensory integration dysfunction.

Assessments:

 Observe feeding in naturalistic environment using foods that are familiar to child
 Therapist should play with child prior to feeding. During play consider systems
(cognitive, motor etc) that may contribute to feeding problems.
 Consider cognitive ability, response to sensory input, communication style, postural
control, ability to manipulate objects and use of toys in functional manner.
 Observe parent feeding
 Observe child eating various textures
 Assess placement of food and utensil in mouth (anterior central placement better
tolerated than posterior and on the side)

Intervention:

1) Oral Desensitization

 Encourage infant to explore mouth with hands

 NUK brush or toothbrush can be used to massage gums
 Rub gums with washcloth applying sustained pressure, texture easily accepted by
children
 Blowing bubbles and making sounds in play makes child become more aware of mouth
and its movements
 Dip rubber toys of toothbrush in fruit juices
 Develop a program that prepares child for oral intake, should only take a few minutes,
use a washcloth in and around mouth before feeding
 Firm pressure helps to increase tolerance to touch

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  Feeding may be better accomplished in chair than holding in arms (human touch may be
too powerful stimulus)
 Adapt food textures: vary textures throughout a meal, start with least tolerated then
move to preferred textures (as a reward)

2) Handwriting

Assessments:

1) Work Samples: look at the child’s written work from typical classroom activities. Compare
this to other student’s work to see the standard and expectations of that classroom.

2) Domains of Handwriting: write the alphabet upper and lower case, copying words (near-
point copying, far-point copying), copying manuscript to cursive, writing dictated words,
composition of sentences.

3) Observation: observe student initiate task and engaged in writing task. Consider interest,
motivation, posture etc.

4) Children’s Handwriting Evaluation Scale for Manuscript Writing (CHES-M) - Grades 1 & 2

 Examines rate and quality of handwriting within a near-point copying task

5) Children’s Handwriting Evaluation Scale (CHES-C) - Grades 3 – 8

 Assesses cursive writing with near-point copying of short paragraphs

6) Denver Handwriting Analysis

 Evaluates cursive handwriting of students grades 3 – 8

 Each task has a time limit per grade: near-point copying, writing the alphabet from
memory, far-point copying, manuscript-cursive transition, and dictation
 Diagnosis and Remediation of Handwriting Problems
 Requires at least 2 years of manuscript or cursive writing
 Child generates a fable, guided by a series of 3 pictures

7) Evaluation Tool of Children’s Handwriting (ETCH) - Grades 1 – 6

 Measures legibility and speed of children’s handwriting (manuscript or cursive)

 Domains: alphabet writing of lower and upper case letters, numeral writing, near-point
copying, far-point copying, manuscript-to-cursive transition, dictation, and sentence
composition

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8) Minnesota Handwriting Assessment

9) Test of Handwriting Skills

Interventions:

 Neurodevelopmental Theory: focuses on postural control and efficient movements.

Involves preparation activities before writing to modulate muscle tone (jumping or
bouncing on a ball or a chair push-up increases tone, slow rocking on a bolster
decreases tone) or to promote proximal stability (yoga poses such as downward facing
dog to bare weight through arms and shoulders)
 Sensorimotor: enhance sensory integration with provision of diverse sensory
opportunities (olfactory, tactile, gustatory, proprioceptive, visual). Writing tools,
surfaces and positions are all considered (eg. scented markers or glitter crayons)
 Biomechanical: focuses on posture, paper position, pencil grasp, writing instruments
and type of paper
 Psychosocial: positive encouragement and reward
 Compensatory: computers

Professional Practice Issues

Topic Key Points

Advertising permitted with restrictions (e.g., no reference to equipment names, etc.)

Child Abuse Definition: “child in need of protection”

physical harm caused by failure to adequately care for child, pattern of neglect or abuse

risk of physical harm

sexual abuse or risk of sexual abuse

refusal of required medical treatment or treatment for emotional or behavioural issues

emotional harm resulting from actions or neglect (or risk of)

abandonment

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 RHP must:

report when has reasonable grounds to suspect physical, sexual or emotional abuse, neglect, risk
or harm (as outlined above)

notify local CAS immediately of suspicions and advise CAS if family notified of suspicions

document all observations, conversations & interactions

Controlled Acts Controlled acts include the following (as per Regulated Health Professions Act (RHPA), 1993):

communicating diagnosis

performing procedure below dermis

setting fracture

moving joints of spine beyond usual ROM

administering substances by injection or inhalation

putting instrument, hand or finger beyond into body openings

prescribing, selling or dispensing drugs

prescribing or dispensing glasses

prescribing or dispensing hearing aids

applying form of energy

fitting dental prostheses or devices

managing delivery of baby

allergy testing

some controlled acts can be delegated to OT’s (communicating diagnosis, setting fracture,
administering substance, putting instrument, hand or finger into body opening;

OT’s may only perform controlled act through delegation from appropriate regulated health care
provider

act can be delegated on single case basis or on ongoing basis

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 OT must record delegation of authority in chart

OT must consider own expertise to perform delegated act and refuse if not competent

Diagnosis OT’s assess abilities to perform occupations and draw conclusions about barriers to OP, and
recommend appropriate interventions it is essential to communicate relevant findings to clients
and this may include labels or names for dysfunctions (e.g., dressing apraxia, etc.) – this is not
considered a diagnosis. BUT if the identified dysfunction suggests presence of disease not already
identified by diagnosing practitioner, OT with client consent (if practitioner not referring source),
must communicate assessment findings.

OT’s may explain how confirmed diagnosis relates to client’s OP.

OT’s may provide information about diseases if disease has already been communicated to client
by diagnosing practitioner.

Documentation record must contain: name, address, DOB, referral source & reason, ax & rx record, copies of all
reports, copies of discharge plans, records of delegated acts, records of cancelled appointments

all parts of record must identify client

all entries must be dated and identify of person making entry must be identifiable

modifications after distribution or signature must be done by addenda

DRAFT documents or notes are not required

errors must be identified and signed or initialed by registrant

records can be kept in computer system with certain provisions

records must be provided to client upon request and to people whom client authorizes (fee may
be charged)

records must be retained for 10 years from date of last entry OR 10 years from day on which client
reached age 18; or until OT ceases to practice

if ceasing practice, OT should attempt to appropriately transfer file to another registrant and/or
notify clients

Essential The knowledge, skills, and abilities that are required for an occupational therapist to practice
Competencies safely, effectively and ethically in any province

84 | P a g e
 To determine the qualifications of candidates for registration and, ultimately, to assist in the
process of determining equivalency

The Essential Competencies Framework:

Assumes professional responsibility

Demonstrates practice knowledge

Utilizes a practice process

Thinks critically

Communicates effectively

Engages in professional development

Manages practice environment

Ethics Article 1: member will demonstrate professional competence as well as integrity, loyalty &
reliability

Article 2: member’s primary concern is welfare of client (includes providing best possible level of
service, reporting unethical conduct, demonstrating respect for client, confidentiality)

Article 3: responsibilities include: comprehensive documentation; appropriate communication;

professional responsibility; appropriate relationships; appropriate recommendations

Article 4: members endeavour to maintain and improve professional skill

Article 5: members have responsibility to help provide for growth and development of profession

Article 6: members will take prompt and appropriate action to manage real or potential conflicts of
interest

Informed consent documentation can be written or oral

Consent
required for: treatment for any health-related purpose; admission to a care facility (nursing home
or home for the aged); provision of personal assistance services (e.g., grooming, feeding, etc.).

see guidelines below

Professional Professional misconduct includes:

misconduct
contravening term of registration

contravening standard of practice of the profession

85 | P a g e
 doing anything to client without consent

abuse of client

practicing while impaired or in conflict of interest

discontinuing professional services that are needed without reasonable cause

sharing information without consent

inappropriately using term, title or designation

failing to keep records in accordance with professional standards

falsifying records

misconduct related to fees (excessive billing, failing to tell client of charges, selling debt, etc.)

Professional OT responsible for:

Practice
own actions

ensuring own competence

defining scope of practice

getting appropriate background information prior to providing service

making appropriate referrals when services not available within own agency or scope of practice

maintaining confidentiality

reporting abuse of minors (under 16) according to CFSA

taking reasonable action re: abuse of competent adult (e.g., elder abuse) with consent of client

taking reasonable action re: danger to incompetent adult

reporting all cases of sexual abuse by regulated health professional to appropriate college

maintaining professional boundaries with clients

obtaining informed consent for services

managing conflicts of interest appropriately

Professional ensure that client is clear about purposes for treatment and intent when doing hands-on
Practice – treatment
Sexual Abuse

86 | P a g e
Prevention when situation arises (e.g., joke, hug, gift, etc.), reinforce professional boundaries with client and
document situation in file

ensure clients are appropriately dressed or draped when doing personal care assessments or
training

choose neutral settings for meetings whenever possible

therapist should dress appropriately and maintain business-like approach in interactions

avoid excessive personal disclosure

Supervision of decision to supervise must take into account OT’s level of knowledge and skill
OT Students
OT must:

familiarize self with student’s curriculum & progress

provide appropriate orientation

design appropriate learning and supervision process

obtain client consent for student involvement

ensure client best interests

Support may assist in delivery of OT service under direction and supervision of OT (may assist in evaluation
Personnel and intervention, prepare supplies, maintain office routines)

OT must ensure:

client understands service to be provided by non-registrant

non-registrant understands accountability to supervising OT

care of client not compromised

supervision of non-registrant includes regular monitoring

following functions cannot be delegated:

interpretation of referrals

initial interviews

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 interpretation of assessment findings

planning of intervention

modification of intervention beyond established limits

interventions where continuous clinical judgement needed to monitor and guide client progress

discharge planning

Surveillance If OT asked to review as part of ax, must:

Material
advise client of existence of material

provide opportunity for client to view and respond (if it will influence your opinion of ax)

keep records of what was reviewed

ensure that identify of person portrayed in surveillance material is not in doubt

if giving an opinion in part based on surveillance material, must consider circumstances under
which material obtained and qualify limitations associated with material

Reflexes

Reflex Age Elicit Reaction

Rooting Birth to 2 Stroke corner of mouth Turn head and move

months tongue

Moro Active at 2 Hold infant in semi-seated Extension of elbows and

mos, position, support the head. fingers, flexion of LE.
inhibited Allow the infant’s head to
Abduction of UE,
at 4 to 6 drop backwards.
followed by adduction.
mos

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Palmar Up to 2 Place finger in hand on Flexion around finger of
Grasp mos ulnar side and push on examiner.
palmar surface.

Plantar Up to 12 Apply pressure to the sole Flexion of toes. Stronger

Grasp mos of the foot. if foot is in dorsi flexion.
Inhibited
by weight
bearing to
stand

Primary Birth to 2 Suspend vertically, allow Attempt to weight bare

Standing mos feet to touch surface

Placing Back of hand or foot is Infant flexes and then

Reaction stroked against under- extends extremity.
surface of a table.

Primary At 2 mos Hold infant vertically. Heel-toe stepping

Walking the pattern.
response
starts to
decrease

Asymmetric Birth to 2 Rotate head to side, hold 5 Arm extends and leg on
al Tonic mos gone seconds the side the infant is
Neck by 4 to 6 turned towards, opposite
(ATNR) mos side flexes. “Fencing
position”

Symmetrica 4 to 6 Hold in prone on forearm. Head Flexion: Flexion of

l Tonic Neck mos, gone Flex and extend head. arms and extension of
by 10 to legs.

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 12 mos Head Extension: Extend
arms and flex legs.

Landau Present at Hold in prone suspension, Corresponds to the

birth. gently raise and lower. development of hip
Integrated Examining postural extension, gluts, and abs.
12 to 24 reflexes, spinal extension,
6 mos: full extension of
mos. head and trunk righting.
legs, maintains horizontal
position.

As body weight
increases, loses ability to
maintain horizontal
position.

Equilibrium Start at 6 to 8 weeks with head movements in prone. Reach

and maturation at 10 to 12 mos. Elicited with vestibular, proprioceptive,
Righting auditory and visual stimuli.
Reactions

Optical Visual input Lifts head

Righting

Labrinthine Hold infant vertically, tilt to Infant rights head.

Righting side

Lateral Hold infant vertically, tilt Righting with flexion and

Righting or side to side. extension of opposites
neck sides to restore upright
righting position.

Neck Trunk rotation Lateral righting, for the

Righting on development of rolling
the Body

90 | P a g e
Body Rolling onto back
Righting on
the Head

Body 6 to 8 mos Roll over

Righting on
the Body

Protective Responses

Forward Starts at 6 Lower infant in prone Extends elbow, followed

mos quickly, moving the head by elbow flexion.
first (tilt baby quickly Reaches forward.
forward)
At 8 mos. also extends
wrists and fingers to
reach.

Sideways Starts at 6 In sitting, push infant Extends hand and

mos sideways. reaches to side

Backward In sitting, push infant Extension of arms

Extension backwards.

Replacements - Hip and Knee

Definition: Hip and knee arthroplasty involves the replacement of the joint with prosthesis.
Typically occurs with osteoarthritis, rheumatoid arthritis, ankylosing spondylitis (chronic
inflammatory arthritis in the spine) or trauma. Two different types of hip replacement:

 posterolateral and
 anterolateral.

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Assessment:

1) ADLs: Klein-Bell ADL Scale

2) Phyical: ROM, MMT, obtain pre-surgery status and post.

 Consider both sides and LE and UE (will be used in transfers).

3) Cognition: will client be able to learn/remember restrictions

Intervention:

1) Hip Precautions:

 Anterolateral: no external rotation, adduction (crossing legs or feet) or extension.

 Posterolateral: no hip flexion greater than 90, no internal rotation or adduction.

2) Knee Precautions:

 Avoid rotation of the knee for 12 weeks.

 May use a knee immobiliser.
 Typically no restrictions on bending the knee; must maintain joint mobility.

3) Weight Restrictions: typically clients are weight bearing within 1 to 3 days of surgery.

4) Patient Education:

5) Home modifications (getting rid of throw rugs, telephone cords, clutter, changing set up, etc)

6) Safe Transfer Techniques (it is always helpful for the client to observe the proper technique
1st)

7) Community Mobility Tips (arranging transportation in the beginning is always important)

8) Assistive Devices

9) Sexual Activity (not recommend for 6 weeks because of movement precautions

10) Training Techniques:

 Assistive Devices: dressing stick, sock aide, long-handled reacher, sponge, shoe horn,
elastic shoe laces, elevated toilet seat, leg lifter, shower chair, bath bench, non-slip mat
for bath and stool for sitting in kitchen. Typically client is restricted from hip flexion

92 | P a g e
 which is involved in donning and doffing socks and shoes and picking objects off the
floor.
 Safety Equipment: grab bars, non-slip mat and supervision as needed.
 Safety Procedures: remain seated for dressing.
 Bed Mobility: Hip: Supine position recommend for sleeping with wedge to prevent
adduction. If sleeping on side, operated side is recommended. Knee: supine with entire
leg slightly elevated. Not recommended to sleep on operated side.

Hip Transfers:

 Chair or commode with armrests: extend operated leg, reach back and sit slowly. Do not
lean forward when sitting down. To stand extend operated leg and push off armrests.
 Bath or Shower: Enter with crutches or walker first, then operated leg (bend at knee)
then unaffected leg.
 Car: bench seats recommended over bucket seats. Back up to seat, hold onto stable part
of car, extend operated leg and sit.

Knee Transfers:

 Bend at the hip, may requires some extension at knee if there are restrictions in
movement (as above with hip for car and commode).

Sensory Integration Dysfunction

Definition: Sensory integration is the ability to synthesize, organize, and process sensory
information received from the body and the environment to produce purposeful, goal directed
responses. Sensory integration, simply put, is the ability to take in information through senses
(touch, movement, smell, taste, vision, and hearing), to put it together with prior information,
memories, and knowledge stored in the brain, and to make a meaningful response.

Sensory integrative dysfunction is a developmental disorder in which the person has difficulty
with the processing of input. There are several types of sensory integrative dysfunction:

Sensory Modulation Disorders:

 Sensory defensiveness (hyper-responsivity, over-reactivity)

o Tactile defensiveness

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 o Gravitational insecurity (when vestibular information is not registered in the
usual way, eg. child does not like being tipped backwards for diaper change)
 Sensory Dormancy/Sensory registration problems (hypo-responsivity, under-reactivity)
 Adaptive Movement Response Disorders
 Vestibular processing disorder
 Developmental dyspraxia
 Sensory Discrimination and Perceptual Disorders
 Tactile discrimination
 Proprioceptive perception
 Visual perception
 Other senses

Assessments:

SENSORY INTEGRATIVE ASSESSMENT AREAS ASSESSMENT TOOLS

DYSFUNCTION

Sensory Modulation Disorder Tactile, auditory, Sensory Profile, Sensory

vestibular/gravity, movement Integration and Praxis test,
level, oral, olfactory and, visual Bayley Scales of Infant
arousal, attention level, postrotary Development, The Berry-
nystagmus, sensitivity to Buktenica Developmental
movement, proprioceptive test of Visual Motor
sensitivity, emotional level Integration, Bruininks-
Osteretsky Test of Motor
Proficiency, Peabody
Developmental Motor
Scales

Tactile Defensiveness Two-point Discrimination, Sensory Integration and

localization of stimulus, Praxis Test, Tactile
stereognosis, graphesthesia, social Sensitivity Behavioural
skills, dressing and undressing, Responses Checklist,
eating, grooming, play skills Touch Inventory for
Preschoolers and

94 | P a g e
 elementary school-aged

Gravitational Insecurity Response to movement in space Sensory Integration and

initiated by others or the action of Praxis Tests
objects, emotional reactions,
posture in relation to gravity,
balance and equilibrium, muscle
tone

Adaptive Movement Reflexes and reactions: protective, DeGangi-Berk test of

Responses: Vestibular righting, and equilibrium, postural sensory Integration, Miller
Processing Disorder responses on the ground and in assessment for
the air, bilateral integration; Preschoolers, Sensory
crawling, climbing stairs, laterality; Integration and Praxis
asymmetrical movements tests, Test of Sensory
Functions in Infants,
Toddler and Infant Motor
evaluation, Bayley Scales
of Infant Development,
Chandler Movement
assessment of infants, the
Infant, Peabody
Developmental Motor
Scales

Dyspraxia Reflex development and DeGangi-Berk test of

maturation, constructional praxis, sensory Integration,
design copying praxis, postural FirstSTEp Screening Test
praxis, oral praxis, sequencing for evaluating
praxis, verbal command praxis, preschoolers, Hawaii Early
vestibular processing, tactile Learning Profile, In-Hand
processing, visual and auditory Manipulation test, Miller
processing, daily living skills, play Assessment for
skills Preschoolers, Pediatric
Evaluation of Disability
Inventory, Sensory

95 | P a g e
 Integration and Praxis
Test, test of Sensory
Functions n Infants, Bayley
scales of Infant
Development

Sensory Discrimination & Sensory awareness and Clinical observation,

Perceptual Disorders responsiveness, visual attention, Checklist of Observable
visual memory, visual Clues to Classroom Vision
discrimination, visual recognition, Problems, Erhardt
visual form, visual imagery, spatial Developmental Vision
perception, auditory and tactile Assessment, Observational
discrimination and perception, Test of Visual Symptoms
proprioceptive and vestibular Associated with Visual
discrimination and perception, Problems, Pediatric Clinical
gustatory and olfactory Vision screening for
discrimination and perception, Occupational Therapists ,
integration skills Sensorimotor Performance
analysis, Sensory
Integration And Praxis
Tests

Assessments cont.

Sensory Integration and Praxis Test: a clinical tool to discover patterns of sensory integration
dysfunction. Used with children 4 years 5 months to 8 year 11 months.

Intervention:

 Individual Therapy: This is the most intensive form of intervention. It is often

recommended as the most effective way to initially help a child gain improved
capabilities when sensory integrative problems affect the child’s occupations at home,
in play, at school, or in the community. Individual sensory integrative therapy can be
classified into two categories: classical sensory integration treatment and compensatory
skill development.
 Classical sensory integrative treatment:
o Developed by A. Jean Ayres.

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 o Always done on an individual basis because the therapist must adjust
therapeutic activities moment to moment in relation to the child’s interest in the
activity or response to a specific challenge or sensory experience.
o Involves a balance between structure and freedom.
o The therapist’s job is to create an environment that evokes increasingly complex
adaptive responses from the child. The emphasis on the inner drive of the child is
a key characteristic of classical sensory integration therapy.
o A sensory enriched environment is designed to evoke active exploration on the
part of the child.
 Compensatory skill development:
o This type of intervention aims to help the child and family develop specific skills
or coping strategies in the face of a sensory integrative disorder.
o Therapy is aimed at training specific skills or using techniques that permit better
performance on a given task. Adaptations may be introduced to help the child
compensate for the problem (e.g. a weighted pencil to provide augmented
proprioceptive feedback regarding the position of the child’s hand).
 Group Therapy Programs: Group therapy programs can be used as a transition from
individual therapy so that the child can apply newly developed skills in a social peer
setting with less intensive support from a therapist. Working with children in a group
provides the opportunity to observe some of the ways in which sensory integrative
disorders interrupt functional behaviour in a social context.
 Consultation: Involves the provision of information to family members, teachers and
others who come into contact with the child to understand the nature of the problem.
o The most important component of a consultation program is providing guidance
for how to cope with the problems that stem from the sensory integrative
dysfunction.
o Making adjustments in the environment, finding ways to manage sound, lighting,
and contact with other people, environmental odours, and visual distractions can
make an important difference in attention, behaviour, and ultimately
performance.

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*Spinal Cord Injuries

Presentation:

Spina Movement Possible Functional Implications Treatment

l
Level

C1-3 Neck flexion, extension, Total assist on ADL Transfer board, power lift,
rotation
Can chew, swallow, Hand splints & mouth stick,
talk (may be limited),
Power recline chair with head,
see hear, smell, taste,
chin or breath control
suck, blow, sense
motion Computer access, environmental
controls,
Bowel and bladder
total assist Direct others in care
Require ventilator

C4 Neck flexion, extension, Total assist on ADL Balanced forearm orthosis &
rotation mouth stick
Breathing
Scapular elevation, Environmental controls,
Shoulder shrug
Inspiration (diaphragm) Wheelchair operated by head chin
Bowel and bladder
or breath control, commode, lift,
total assist
pressure relief mattress
Communication is
Direct others in care,
intact

C5 Shoulder flexion, UE self care activities Dorsal wrist support (hold

abduction & extension, (Grooming, dressing utensils)
with adapted aids)
Elbow flexion & Manual and power wheelchair
supination, Unable to do lower

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 scapular adduction, and extremity ADLs
abduction
Power wheelchair with arm drive
control, tilt for pressure relief

C6 Scapular protraction & Potential Universal cuff & adapted

horizontal adduction independence on self equipment
care activities
Forearm supination
Propel manual wheel
Radial wrist extension
chair with modified
Tenodysis rims

Transfer board or
mechanical lift

C7-8 Elbow extension, Independent in self Wheelchair

care, ADLs with some
Forearm pronation, Strength & ROM
assistance
Wrist extension &
Transfers independent
flexion,
with or without
Thumb extension & transfer board
abduction
Propel wheelchair with
Passive finger flexion modified rims.

T1-T9 UE in tack Independent in self Hand strength

care, meal preparation,
Limited upper trunk
light housecleaning,
stability
driving & vocational
Increased endurance pursuits
secondary to innervation
Perform lifts &
of intercostals
transfers

T10- Full trunk stability Independent in self UE strengthening and

care, wheelchair

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L1 population, IADLS, conditioning
transfers, bowel &
Manipulating environment
bladder
Vocation & leisure
Mobility varies

L2-S5 Good trunk stability, Independent in ADL,

bladder & bowel
Partial to full control of
LE Ambulation with some
assist (wheelchair,
AFOs, crutches)

Level Motor Abilities Functional Goals for Survivor

C1-C3 Limited movement Breathing: Depends on a ventilator for breathing.

of head and neck Communication: Talking may be very limited or impossible. If
ability to talk is limited, communication can be accomplished
independently with a mouth stick and assistive technologies like a
computer for speech or typing. Effective communication allows the
survivor to direct caregivers with daily activities such as bathing,
dressing, personal hygiene, transferring, and bladder and bowel
management.
Daily tasks: Assistive technology allows for independence in tasks
such as turning pages, using a telephone and operating lights and
appliances.
Mobility: Can operate an electric wheelchair by using a head
control, mouth stick, or chin control. A power tilt wheelchair allows
independent pressure relief from sitting in one position.

C3-C4 Usually has head Breathing: May initially require a ventilator for breathing but
and neck control. usually adjusts to breathing full-time without ventilator assistance.
Individuals at C4 Communication: Normal.

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 level may shrug Daily tasks: With specialized equipment may have limited
their shoulders. independence in feeding and independently operating an
adjustable bed with an adaptive controller.

C5 Typically has head Daily tasks: Independence with eating, drinking, face washing,
and neck control, brushing teeth, face shaving and hair care after assistance in
can shrug shoulder setting up specialized equipment.
and has shoulder Health care: Can help in preventing pressure ulcers by leaning
control. Can bend forward or side-to-side.
elbows and turn
palms face up.

C6 Has movement in Daily tasks: With help of specialized equipment can perform with
head, neck, greater ease and independence daily tasks of feeding, bathing,
shoulders, arms grooming, personal hygiene and dressing. May independently
and wrists. Can perform light housekeeping duties.
shrug shoulders, Health care: Can independently perform skin checks, turn in bed,
bend elbows, turn and relieve pressure while sitting.
palms up and Mobility: Some individuals can independently do transfers but
down and extend often require a sliding board. Can use a manual wheelchair for daily
wrists. activities but may use power wheelchair for greater independence.

C7 Has similar
Daily tasks: Able to perform household duties. Needs fewer
movement as an
adaptive aids in independent living.
individual with C6
Health care: Able to do wheelchair pushups for pressure relief.
with added ability
Mobility: Daily use of manual wheelchair. Can transfer with greater
to straighten
ease.
elbows.

C8-T1 Has added strength Daily tasks: Can live independently without assistive devices in
and coordination feeding, bathing, grooming, oral and facial hygiene, dressing, and
of fingers with bladder and bowel management.
limited or even Mobility: Uses manual wheelchair. Can transfer independently.

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 normal hand
function.

T2-T6 Has normal motor Daily tasks: Should be totally independent with all activities.
function in head, Mobility: A few individuals are capable of limited walking with
neck, shoulders, extensive bracing. However, this requires extremely high energy
arms, hands and and puts stress on the upper body, which can lead to damage of
fingers. Has upper joints. There is no functional advantage with this kind of
increased use of rib walking.
and chest muscles
and may have
some trunk
control.

Presentation Continued:

Complications of Spinal Cord Injuries:

 Skin Breakdown: pressure sores because of sensory loss; person cannot feel pressure,
pain or heat.
 Decreased Vital Capacity: occurs with cervical or high thoracic lesions. Increased risk for
respiratory tract infections.
 Osteoporosis of Disuse: typically occurs in legs and can result in fractures.
 Orthostatic Hypotension: lack of muscle tone in legs and abdomen leads to pooling of
blood resulting in decreased blood pressure.
 Autonomic Dysreflexia: occurs in lesions above T4 to T6 when there is a stimulus such as
a distsended bladder, fecal mass, thermal or pain stimuli. Immediate pounding
headache, anxiety, perspiration, flushing, chills, hypertension etc. A life threatening
medical emergency. Check catheter for block.
 Spasticity: involuntary muscle contraction below the injury. Can be used to advantage
for transfers and bed mobility.
 Heterotopic Ossification: development of bone in abnormal locations.

Assessments:

 Physical: be sure of medical restrictions and precautions. Begin by testing PROM to

determine pain-free range prior to MMT.

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  Sensation: light touch, pain and kinaesthesia.
 Reflexes: present or not
 Wrist and hand functioning and strength (dynamometer)
 Clinical observation of oral motor control, head and neck control, LE functional muscle
strength and total body functioning.
 Cognition: may be a brain injury present.
 Mood or affect
 ADL observation: functional tasks, Barthel Index, FIM, Klein-Bell ADL Scale
 Social Environment: family and friends available for support upon discharge.
 Psychosocial: adjustment following injury.

Interventions:

 Goals:
 ROM: maintain and increase joint ROM with PROM, splinting and positioning.
 Strength: strengthening innervated and partially innervated muscles with activity.
 Endurance: increase physical endurance
 ADLs: maximize independence
 Leisure: explore leisure interests
 Vocational: explore potential and interest
 Psychosocial: aided in adjustment to disability.
 Equipment: evaluate need and educate re: use.
 Home Accessibility: recommendations and modifications.
 Directing Care: communication skills for directing caregivers.

Acute Phase:

 Evaluate positioning and need for hand splinting. Splints should be dorsal to allow for
maximal sensory feedback.
 ROM: active ROM and active-assistive should be performed with tolerance levels.
 Encourage participation in ADLs; use devices as appropriate (eg. universal cuff)
 Initiate caregiver education and home modifications for discharge.

Active Phase:

 Sitting: work on upright posture and sitting tolerance in wheelchair and pressure
relieving techniques for sitting.
 Active and passive ROM to prevent contractures.

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  Tenodesis: if client has wrist extension some tightness over the long finger flexor
tendons can be deliberately developed to encourage some functional grasp. Range
finger flexion with full wrist extension.
 Strengthening: shoulder girdle, triceps, pectoralis and latissimus dorsi for transfers and
weight shifting in wheelchair.
 Equipment: universal cuff, wrist cock-up splint, plate guard, cup holder, straw, nonskid
mat, soap holder, wash mitt, transfer board etc.

Spina Bifida

Definition: A congenital defect of the vertebral arches and spinal column. The neural tube fails
to close during embryo development.

 Spina Bifida Occulta : minor defect with no malformation of spinal cord.

 Meningocele : a type of spina bifida cystica that involves an opening in the spine with an
exposed pouch of CSF and the meninges.
 Myelomeningocele : exposure of CSF, meninges and nerve roots.
 Hydrocephalus : impairment of CSF drainage resulting in increased intracranial pressure
and enlargement of the ventricles, often accompanies myelomeningocele. The degree
of impairment depends on the level and degree of spinal cord involvement.

Presentation:

 Sensory and motor disturbances are displayed below the level of the lesion often with
issues of continence (often require catherization).
 Most lesions are in the thoracic or lumbar spine resulting in lower extremity flaccid
paralysis.
 Children with hydrocephalus and/or significant motor deficits may demonstrate sensory
processing and perceptual problems (and fine motor difficulties related to perceptual
issues). Hydrocephalus can also result in intellectual disabilities and seizures. Cocktail
party syndrome may result (hyperverbal; expressive language more advanced than
receptive).
 Orthopaedic problems such as scoliosis, clubfoot, arthrogryposis or dislocated hip may
be present.
 Cognition: Often have issues with eye-hand coordination (perceptual-motor), attention,
hyperactivity, learning difficultiess, memory, organization, sequencing, reasoning and
problem-solving and motivation.

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  Latex allergies are very common (due to sensitivities developed as a result of surgeries).

Assessments:

Areas to Assess:

 ADL
 IADL
 Play skills
 Fine motor (due to visual perceptual impairment, dyspraxia) such as handwriting
 Vision and perception
 Motor planning
 Sensation (no sensation below level of lesion; may be hyper, hyposensitive to stimuli)
 Bowel and bladder continence
 Cognition
 Psychosocial issues (self-concept, coping)

Assessments (Standardized):

1) Bayley Infant Development Scale

2) VMI (visual-motor integration, 3-18 yrs)

3) TVPS (visual perception, 4 yrs- 12 yr 11m)

4) Vineland Behavioural Scales (self-care, independent living skills)

5) WeeFIM (self-care, independent living skills, 6m – 7 yrs)

6) Sensory Profile (3-10 yrs)

Intervention:

 Orthotic prescription, preventing contractures

 W/C prescription. Presure care is important due to decreased sensation, mobility and
incontinence
 Assistive device prescription
 Self care: especially bowel and bladder routines, skin care (pressure sore prevention)
 IADLs, community integration & safety
 School and handwriting
 Transition

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*Stroke

Definition: Diseases that result from changes in the blood vessels supplying the brain leading to
death of cells; may be characterized by hemiplegia, sensory dysfunction, aphasia and
dysarthria, visual field deficits, and mental and intellectual impairment.

 Hemiplegia – condition in which half of the body is paralysed

 Hemiparesis – weakness of the Left or Right side of the body
 Sensory (dysfunction) – having to do with sensations or the senses; including peripheral
sensory processing (e.g. sensitivity to touch) and cortical sensory processing (e.g. 2-
point and sharp/dull discrimination).
 Aphasia – absence of cognitive language processing ability that results in deficits in
speech, writing, or sign communication. Can be receptive, expressive, or both.
 Dysarthria – group of speech disorders resulting from disturbances in muscular control.
 Dysphagia – difficulty swallowing.
 Dyspraxia – difficulty or inability to perform a planned motor activity when the muscles
used in this activity are not paralysed.
 Ischemic Stroke: includes a group of disorders in which the symptoms are caused by an
insufficient supply of blood to the brain. The decreased blood flow is caused by
thrombosis (a plug or clot in a blood vessel that remains in place), embolism (a plug or
clot brought through the blood from a larger vessel and forced into a smaller one), and
reduction of blood flow such that not enough oxygen and glucose are supplied. (80% of
strokes).
 Hemorrhagic Stroke: massive bleeding into the substance of the brain. Most frequent
cause is high blood pressure/hypertension. Prognosis is generally poor.

Presentation:

Region of Implications of Stroke Hypothesized Functional

Stroke Implications

Right Visual-Spatial Perceptual Disorders: May only dress or groom

Hemisphe one side of the body.
Left-sided neglect: unilateral neglect in 22-46% of
re
acute right CVA, during acute phase head and eyes May only eat food on one
deviate to the left side of plate.

May be unaware of

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 Figure-ground disorientation people or cars
approaching from left
Constructional apraxia (inability to plan and initiate
side (safety concern).
the movement)
Independent sitting
Emotional Disorders:
Stair climbing
People with right CVAs may speak well, so their
abilities can be overestimated Lack of insight into own
deficits (safety)
Emotional indifference or flat affect
Strained relationships
Impulsivity
Impulsivity (mobility,
Emotional lability
safety)
Depression occurs in 50% of people that have had
Communication
strokes
difficulties can negatively
Communication Problems: impact social interactions

Aphasia rarely occurs in right CVA

Difficulty using language effectively

Turn taking rules of conversation

Left Aphasia: Apraxia of speech

Hemisphe
In 97% of people, the left hemisphere is dominant for Apraxia of gait
re
language
Apraxia of dressing
Expressive (Broca’s) aphasia is most common with left
Difficulty walking,
CVAs
dressing, communicating,
Apraxias: transferring

Disorder of voluntary movements, despite adequate ADLs (generally)

strength, mobility, sensation, comprehension and
coordination

Emotional Disorders:

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 Depression occurs in 50% of people that have had
strokes

Occasionally people with aphasia demonstrate

frustration and rage

Brain Diverse manifestations, can impact occipital, medial Eating, feeding

Stem temporal lobes, brainstem or cerebellum
Walking and sitting
Isolated brainstem strokes spare cognitive and (vertigo)
language functions
ADLs (dressing, preparing
Medulla: Vertigo, nausea, vomiting, sensory loss in meals etc. limb tremor)
ipsilateral face and contralateral limb, dysphasia
(difficulty swallowing), dysarthria

Pons: Contralateral hemiparesis or paralysis

Cerebellum: Unilateral limb ataxia, truncal ataxia,

vertigo, headache, may become comatose

Midbrain: Contralateral hemiparesis, tremor in limb,

lateral gaze only, contralateral sensory loss

Lacunar Occur at the end of arteries and cause small cerebral Eating, feeding
Infarcts infarcts
Fine-motor: handwriting,
Common with hypertension dressing, typing

Often mistaken for a TIA Safety (sensory issues eg.

water temperature)
Can sometimes be asymptomatic

Syndrome Manifestations:

Pure motor hemiparesis or pure sensory signs on half

of body

Dysarthria

(clumsiness and mild weakness of hand)

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 Dysphasia (swallowing, weakness half of face and
tongue)

Ataxic hemiparesis

Assessments:

1) COPM: establish goals

2) ADLs: FIM evaluates independence of 18 items in 6 areas; self-care, sphincter control,

transfers, locomotion, communication, and social cognition (in all there are 13 motor and 5
cognitive items); designed for patients of all ages and isn’t diagnosis specific.

3) ADLs: Barthel Index measure of ADL disability that ranges from 0-20 or 0-100 (by multiplying
each item by 5); includes ten items: bowels, bladder, feeding, grooming, dressing, transfer,
toileting, mobility, stairs, and bathing.

4) Cognition: MMSE, Cognistat, CCT

5) Visual-Perceptual: Rivermead Visual-Perceptual Assessment Battery

6) Motor Free Visual Perception Test: measures 5 areas of visual perception (spatial
relationships, visual discrimination, figure-ground, visual closure, visual memory);takes approx.
10 mins. to administer.

7) OSOT Perceptual Evaluation – designed to identify perceptual impairments in adults with

neurological disorders and was standardized using patients with CVA diagnoses; evalutes
scanning, spatial neglect, motor planning, copying 2-D and 3-D designs, body puzzle, drawing a
person, R/L discrimination, clock drawing, peg board, house drawing, shape recognition, colour
recognition, size recognition, figure-ground discrimination, proprioception, and R/L
stereognosis; takes approx. 70 mins to administer.

8) Physical Assessment:

 Chedoke-McMaster Stroke Assessment: developed for use with in-patient and day-
hospital clients who are from 1 week to several years post-stroke; consists of the
Impairment Inventory which determines the presence and severity of common physical

109 | P a g e
 impairments following a CVA (assesses shoulder pain, postural control, arm, hand, leg
and foot) and the Disability Inventory which measures functional outcome (assesses
gross motor function and walking); takes 45-60 mins
 Chedoke-McMaster Stroke Assessment:

Stag Characteristics
e

1 Flaccid paralysis

Stretch reflexes are absent

Active movement cannot be elicited with stimulation or volitionally

2 Spasticity is present

Resistance to passive movement

No voluntary movement

Some reflexes elicited with stimulation

Synergies of flexor and extensor movements elicited with stimulation

3 Spasticity present

Synergistic movements can be voluntarily elicited

4 Spasticity decreases

Some synergies can be reversed

5 Spasticity only evident with rapid movement and at extremes of range

6 Coordination and movement patterns nearly normal

Abnormal movements occur with more complex movement patterns

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7 Normal patterns appropriate for age and complexity

No evidence of impairment

9) Physical Assessment: MMT, AROM, PROM, goniometry, sensation, proprioception,

stereognosis, JAMAR, dynamometer.

Interventions:

 Neurodevelopmental Therapy (NDT): underlying theory is that during recovery, a

patient will typically overuse the uninvolved side, compensating for the loss of sensory
and motor function on the hemiplegic side. Resulting problems in posture, alignment,
balance, strength, tone, and coordination often lead to less effective patterns of
movement and may eventually cause orthopedic problems, pain and decreased safety
o The therapist develops a program to help the patient avoid abnormal patterns of
movement. The Program is based on:
o relearning normal movement rather than using compensatory strategies (i.e
hiking shoulder up to grasp an object rather then reaching using both the
shoulder and elbow in a more fluid motion)
o encouraging use of both sides of the body
o one central principle is that alignment and symmetry of the trunk and pelvis are
necessary for good alignment of the extremities.
o There are different types of NDT:
 Bobath: aims to reduce spasticity and synergies by using inhibitory
postures and movements to facilitate normal, autonomic responses
 Brunnstrom: encourages flexor and extensor synergies during early
recovery, assuming synergies will result in voluntary movement
 Proprioceptive Neuromuscular Facilitation: uses person’s stronger movement patterns
to strengthen weaker motions. Uses manual stimulation and verbal feedback to induce
movement
 Motor Relearning Programme: functional training for key motor tasks. Therapists
analyse task to determine which component cannot be performed. Trains patients in
component (Carr and Shepherd)
 Constraint Induced Movement Therapy (CIMT): CIMT involve restraint of the unaffected
limb to encourage use of the affected limb. There is some evidence that CMIT may be
more beneficial than other therapies during the acute stage. During the chronic stage,
there is strong evidence that CMIT is more beneficial than other therapies. Individuals

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 that receive CIMT must have some wrist and hand movement for intervention to be
effective.

Traumatic Brain Injury

Definition: Closed Head Injury: skull remains intact. Common in MVAs or falls where there is a
rapid acceleration and deceleration of the head.

 Open Head Injury: skull is penetrated, example gunshot.

 Primary Damage: original physical impairment resulting from event.
 Secondary Damage: damage that is produced as a result of primary tissue damage.
Example are: increase in intracranial pressure, cerebral edema, obstruction of CSF,
subarachnoid haemorrhage, post-traumatic epilepsy and hydrocephalus.

Presentation:

 Primitive reflexes
 Impaired muscle tone
 Decreased motor control and coordination: ataxia from impairment of the cerebellum
 Decreased muscular strength and endurance: deconditioning
 Postural deficits: result from imbalance in muscle tone throughout the body
 Decreased ROM
 Decreased sensation and impaired propioception
 Decorticate Rigidity: in acute phase, when comatose UEs are in spastic flexed position.
LEs are in spastic extended position. Results from damage to cerebral hemispheres
 Decerebrate Rigidity: all extremities in position of spastic extension, adduction and
internal rotation. Results from damage to brain stem and extrapyramidal tracts
 Dysphagia
 Cognitive Status:
o Reduced attention and concentration
o Impaired memory
o Impaired initiation or termination of activities: perseveration, person cannot end
neurological pattern.
o Decreased safety awareness and poor judgement, impulsivity and consequence
awareness

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 o Delayed processing of information
o Impaired executive functions and abstract thinking: planning and following
complex activities
o Generalization
 Visual Status: can be impacted
 Perceptual Skills: often occurs with right hemisphere damage
 Psychosocial Factors:
o Self-Concept: often long-term memory stays intact, whereas short-term memory
is impaired. Difficulty reconciling post-injury self with memories of pre-injury
status
 Social Roles: isolation, difficulty forming relationships, loss of pre-injury relationships
 Independent Living Status: decreased sense of personal control
 Dealing with Loss: denial, resistance to therapy
 Affective Changes: often with left hemisphere injuries depression and emotional lability
is common
 Behavioural Factors: social inappropriateness and disinhibition, common with frontal
lobe injuries

General Overview of Brain Anatomy:

 Frontal Lobe: decision making, fine motor control, goal setting, judgment, higher-level
thinking, planning, problem solving
 Parietal Lobe: interprets form & space information; processes sensory information from
senses, muscles and joint; regulated input and information for organizing and processing
 Temporal Lobe: auditory processing and expressive and receptive language; speech,
some emotions, and dreams
 Occipital Lobe: Processes visual info & integrates with other centers
 Limbic/Diencephalon: Regulation of emotions, alertness, and arousal; ability to organize
and regulate information, memory, impulse control, appetite, sexual arousal, and body
temperature. Assists in communication between departments.
 Cerebellum: responsible for large muscle control, posture, balance, equilibrium, and
reflexes
 Brain Stem: Controls essential body functions, keeps basic operations going, regulates
attention and incoming information

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Assessments:

1) Glasgow Coma Scale: Used to assess levels of consciousness after a TBI. 3 scales:

a. Eye Opening (Scale 1 to 4; where 4 is best response-opens eyes on own)

b. Best Motor Response (Scale 1 to 6; where 6 is best response-follows simple commands;
1 to 5 are responses to a pinch from examiner)
c. Verbal Response-talking (Scale 1 to 5; where 5 best response-carries on a conversation
correctly and tells examiner where he is, who he is, and the month and year)

2) Rancho Los Amigos Scale:

 Purpose: To measure levels of awareness and cognitive function. Note scale can be
used anytime during recovery phase. Note: not intended to be used as a predictive
scale.
 Level 1: No response-Unresponsive to any stimulus
 Level 2: Generalized response-Nonspecific, inconsistent, and non-purposeful responses
to stimuli (often only to pain)
 Level 3: Localized Response-Response directly related to type of stimuli presented, yet
responses still inconsistent and delayed
 Level 4: Confused-agitated-Heightened state pf activity, confusion, disorientation; may
exhibit aggressive bhvrs, agitation appears related to internal confusion.

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  Level 5: Confused-inappropriate-Appears alert, responds to simple commands,
distractible, does not concentrate on task, agitated to responses to external stimuli,
verbally inappropriate, does not learn new information
 Level 6:Confused-Appropriate-shows goal-directed bhvrs but dependent on external
input for directions, able to follow simple directions, shows carryover for tasks that are
relearned, issues continue with memory & delayed responses
 Level 7: Automatic-Appropriate-appears appropriate and oriented, goes through daily
activities automatically (but robot-like), requires at least minimal supervision for
learning and safety, requires structure, judgment still impaired
 Level 8: Purposeful and Appropriate-functional in all areas; able to learn new activities,
able to recall past and present events. Independent, needs no supervision.

Assessments Early Stage:

 Observe:
 Cognition: orientation and alertness
 Vision: scan, maintain eye contact
 Sensation: response to stimuli
 Joint ROM: rigidity, tone, spacticity
 Muscular strength
 Motor control
 Dysphagia
 Psychosocial or behavioural factors

Interventions:

 Acute/ICU: Assist with stabilizing client medically. By assisting to monitor vital signs,
neurological signs and preventing secondary complications (ROM, splinting, positioning,
assisting with non-verbal communication techniques, bed mobility, sensory stimulation,
assisting with orientation, family education), assist with psychosocial issues
 Rehabilitation: ADLs including transfers, self-feeding-dysphagia, IADLs, behavioural
management, memory remediation and compensation strategies, energy conservation,
organizational strategies, safety education, re-teaching of skills, wheelchair
management, social skills training, environmental recommendations
 Community: same as above, home safety, assistive devices, driving/transportation,
family education, vocational & work skills training

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 V

Vocational Rehabilitation

Vocational rehabilitation is required for both mental health consumers and physical
rehabilitation.

Mental Health VR:

Assessments:

 Interest Inventories
 Aptitude Tests: General Aptitude Test Battery, scores can be related to the Dictionary of
Occupational Titles. Attempt to find a fit between the person’s aptitudes and the
aptitudes required for a specific job
 Situational Assessments: client evaluated in a real or simulated work environment
 Job Shadowing: used in conjunction with interest testing
 Note: due to the typical age of onset of mental illness, many clients may not have had
the opportunity to develop work skills and gain experience

Interventions:

 Volunteer Work: clients can choose their hours and type of activity
 Sheltered Work: typically involves factory or contract work. Part of an institution or
work training site. Criticized for inadequate remuneration and lack of meaningful
opportunities for growth
 Cooperatives: organization run by consumers and develops contracts. Enables client to
work when they are able
 Affirmative Business: consumer run business that works in partnership with the
community and local businesses
 Transitional Employment: started through the Clubhouse movement. A work-ordered
day will provide prevocational and vocational development
 Supported Employment: involves job coaches, place-then-train model. On going
support offered to consumer
 Work Hardening: clients participate in gradual exposure to a real or simulated job.
Improve physical and mental tolerance for work demands

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Steps to Vocational Rehabilitation in Mental Health:

 Set the scene: discuss balance of work, rest and play with client. Explore how illness
uniquely affects client
 Gather information: work history. Do not ask for client to tell you about his or her job,
that can be defeating to discuss “failures”. Ask them to tell you what they liked and
didn’t like about work-related experiences
 Evaluate personal variables: interests, aptitudes, tolerance
 Evaluate environmental requirements: what does the work place expect? Clients work
habits, skills and personality
 Continued support to keep the job.

Physical Health VR:

Assessments:

 Job Site Analysis: therapist looks at work environment and tasks. Can involve
measurements, video camera and timing of activities
 Physical Demands Analysis: general to the position, not to the specific client. Systematic
procedure to quantify and evaluate the physical and environmental demands of a job.
Part of a Job Analysis. Involves interview and observation.
 Functional Capacity Evaluation: specific to the client’s situation. Obtain information
about the client’s capabilities and physical tolerances. Involves standardized and non-
standardized assessments. Examples of tools: Nine Hole Peg Test, Jebsen Hand Function
Test, Minnesota Rate of Manipulation, Purdue Peg Board.

Interventions:

 Return to Work: allows client to maintain identity as a worker.

 Work Conditioning: fitness programs (flexibility, strengthening and cardiovascular
exercise) and non-specific, job-simulated work tasks.
 Work Hardening: job-specific tasks that progress the client to the demand level of the
job. Includes modified work schedules, psychosocial interventions, body mechanics and
pain management.
 Modified Work Program: similar to work conditioning and work hardening but it occurs
in work place.
 Ergonomics: fitting the task to the worker.

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 PART II – MENTAL HEALTH

Anxiety Disorders

Definition: A group of disorders in which anxiety or anxiousness are central features. Anxiety
can be defined as apprehension of danger and dread accompanied by restlessness, tension,
tachycardia (increased heart rate), and dyspnea (shortness of breath) unattached to a clearly
identifiable situation

The DSM-IV delineates 5 major categories:

 panic disorders
 phobic disorders
 obsessive compulsive disorder
 post-traumatic stress disorder
 anxiety states

Presentation:

 Psychological complaints: subjective distress, worry, dread, mental anguish

 Somatic symptoms: sweating, shortness of breath, rapid pulse, tremors

1) Panic Disorder:

 Characterized by recurrent unexpected panic attacks, where at least one is followed by:
o Persistent concern of having another attack
o Worry of implications of attack or its consequences
o Change in behaviour related to attacks
o Without agoraphobia (this is a panic attack)
o With agoraphobia – symptoms of panic attack accompanied by extreme fear of
being in a public place or outside the home
o Panic attack is discrete period of intense fear (10 minutes) where 4 of the
symptoms are present: palpitations, sweating, tremors, shortness of breath,
feeling of chocking, chest pain, fear of dying, fear of losing control, dizziness.

2) Phobic Disorder:

 Persistent fear that is excessive or unreasonable, cued by presence or anticipation of

specific object/situation

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  Exposure to phobic stimulus provokes immediate anxiety response
 Individual recognizes that the fear is unreasonable or excessive
 Situations are avoided or endured with intense anxiety or distress
 Avoidance, anticipation, or distress in feared situation interferes with normal routine,
occupational functioning, or social activities with marked distress about having the
phobia

3) Obsessive Compulsive Disorder:

 Obsession:
o Recurrent thoughts, impulses, images experienced at some time during a
disturbance, which are intrusive and inappropriate, causing marked anxiety or
stress
o Thoughts/impulses/images which are not simply excessive worries (real life
problems)
o Individual attempts to ignore or suppress thought/impulse/image
o Individual recognizes it is all a product of their mind
 Compulsion:
o Repetitive behaviour or mental act an individual feels driven to perform
o These actions are aimed to prevent or reduce distress but are not connected in a
realistic way
o These actions are recognized to be excessive or unreasonable

4) Post Traumatic Stress Disorder:

 Individual exposed to traumatic event where both are present:

o Experienced/witnessed/confronted with event involving actual/threatened
death or serious injury
o Response involved intense fear, helplessness, or horror
o The traumatic event is persistently re-experienced through: recurrent or
intrusive recollections, dreams, acting or feeling as if the event is re-occurring, or
intense psychological distress
o Persistent avoidance of stimuli associated with the trauma
o Persistent symptoms of increased arousal

5) Generalized Anxiety Disorder:

 Excessive worrying for a period of 6 months concerning past, or anticipated events,

relationships, losses, etc.

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  Individuals find it difficult to control the worry
 Individuals experience restlessness, fatigue, difficulty concentrating and attending to
information, disturbed sleep, eating, and sexual arousal, irritability, muscle tension

6) Social Anxiety Disorder:

 Fear of social situations or performing in public

 Embarrassment is one emotion associated with performance anxiety
 Becomes a significant problem when it begins interfering with function (school, work,
relationships, activities)

Assessments:

 Assessment Areas:
o ADLs and IADLs
o Productivity values, tasks and skills
o Leisure interests and skills
o Problem-solving skills
o Time management
o Social Skills
 Assessment Tools:
o Role Checklist
o Social Network Map
o Stress Management Questionnaire
o Quality of Life Interview: assess life circumstances of persons with mental illness.
Standardized assessment that takes 30 to 45 minutes. Considers: living situation,
family relations, social relations, leisure, work, finances, safety and health.
Clients answer questions with a 5-point ordinal scale.

Interventions:

 Self Care:
 Functional behavioural training – program is designed to increase functional
performance by reducing symptoms associated with that activity
 Graded activity/activity analysis
 Sensorimotor:
 Relaxation training, breathing, progressive muscle relaxation, visualization, autogenic
training (self directed verbal commands)
 Cognitive:

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 o Education/lifestyle alterations (stress management, exercise, resolving
interpersonal conflict, increasing down time, reducing stimulant intake, changing
attitude toward perfectionism, need to control, and need to please)
o Cognitive approaches (CBT)
 Time management
 Psychosocial:
 Assertiveness training
 Social skills training
 Expressive activities (structured crafts)
 Journaling
 Environmental: community mobility and re-entry strategies
 Medication

Bipolar Disorder

Definition: A mood disorder in which one experiences manic episode, depressed episodes or
mixed episodes. There may be predominance of any phase at a particular time or symptoms of
more than one phase may occur simultaneously.

Presentation: Manic episode is excessive elation, expansiveness, irritability, talkativeness,

inflated self esteem, and flight of ideas. Mixed episode is a combination of manic and
depressive symptoms. Major depressive episode is intense sadness or despair, no interest in
activities once enjoyed, loss of energy or fatigue, sleep difficulties, changes in appetite,
difficulty concentrating, constant thoughts of death or suicide. Hypomanic episode is a milder
form of mania, which is characteristic of bipolar 2 disorder.

 Bipolar I disorder is characterized by one or more manic episodes or mixed episodes

(symptoms of both a mania and a depression occurring nearly every day for at least 1
week) and one or more major depressive episodes. Bipolar I disorder is the most severe
form of the illness marked by extreme manic episodes.
 Bipolar II disorder is characterized by one or more depressive episodes accompanied by
at least one hypomanic episode. Hypomanic episodes have symptoms similar to manic
episodes but are less severe, but must be clearly different from a person’s non-
depressed mood. For some, hypomanic episodes are not severe enough to cause

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 notable problems in social activities or work. However, for others, they can be
troublesome.
 Cyclothymic disorder is characterized by chronic fluctuating moods involving periods of
hypomania and depression. The periods of both depressive and hypomanic symptoms
are shorter, less severe, and do not occur with regularity as experienced with bipolar II
or I. However, these mood swings can impair social interactions and work. Many, but
not all, people with cyclothymia develop a more severe form of bipolar illness.
 Bipolar Disorder Not Otherwise Specified: When the bipolar disorder is not
characterized by any of the above mentioned types of bipolar disorder. The experiences
of bipolar disorder vary from person to person. Occasionally someone will experience
the symptoms of a manic episode and a major depressive episode, but not fit into the
above mentioned types of bipolar disorder. This is known as Bipolar Disorder Not
Otherwise Specified. Just like the other types of bipolar disorder, Bipolar Disorder Not
Otherwise Specified is a treatable disorder.

Assessments:

1) COPM

2) Quality of Life Interview: assess life circumstances of individuals with severe mental illness in
terms of their actual experiences and feelings about those experiences. The QOL interview
assesses a wide range of life domains such as; living situation, social relations, leisure activities,
finances, safety and legal problems, work, school and health.

3) Mental Status Exam: Focus areas for examination include:

 Alertness and Orientation

 Language (speech flow and content)
 Memory
 Perceptions
 Thought processes (coherent or disorganized)

4) Bay-Area Functional Performance Evaluation (BaFPE): assessment of cognitive, affective and

performance skills in daily living tasks and social interaction skills.

5) Kohlman Evaluation of living Skills: determine ability to function in 17 basic living skills in five
areas: self-care, safety and health, money management, transportation and telephone, and
work and leisure.\

6) Beck Depression Inventory

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Intervention:

 Acute phase – in which the focus is on target symptom reduction and preliminary
education about the illness and its treatment. This phase may be treated in the more
intense levels of care and with emphasis on pharmacotherapy. Severe vegetative
disturbances, the presence of psychosis and self-destructive intent make patient safety
the primary concern.
 Stabilization phase – in which the patient is either transitioning between the acute and
maintenance phases, or newly presenting active, non-life-threatening symptoms
severely affecting social, occupational or educational functioning. The emphasis is on
stabilization of the symptoms, stress reduction and relapse prevention. Education of the
patient and the family is emphasized during this phase with the focus on reintegration
into the family, workplace and community.
 Maintenance/rehabilitation phase during which the emphasis shifts toward stable
functioning, improvement in quality of life and prevention of recurrence. There is a
focus toward enhancement of social, marital, community and occupational functioning.
Education continues to be a major component of treatment to empower the patient and
family to understand the potential long-term prognosis.

The following offers interventions associated with each of the above approaches:

 Supportive therapy: involves the development and maintenance of a therapeutic

alliance to aid in providing clear explanations for a patient’s symptoms. This should also
monitor and intervene when self-destructive impulses arise. Supportive therapy also
addresses the patient’s development of interpersonal relationships, improvement in
vocational skills and living conditions.
 Cognitive therapy: this approach focuses on understanding and eliminating irrational
beliefs and distorted attitudes toward self and the social environment.
 Interpersonal therapy: aids the patient in recognizing, exploring and resolving
precipitants involving interpersonal losses, role disputes and transitions, social isolation,
occupational difficulties or deficits in social skills.
 Medication: as needed to control symptoms experienced which interfere with ability to
function independently
 NOTE: Main focuses are on education about illness, compliance with medications,
destigmatization, education on recognizing social and occupational functioning
 Routine: Establish a routine with instructions for daily activities.
 Activity: Increase activity with participation in recreational activities, encourage skill
development for sense of mastery.

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  Relaxation techniques
 Groups: encourage social interaction and development of social skills

* Depression

Definition: Characterized by a depressed mood or loss of interest or pleasure in daily activities,

lasting for at least a 2 week period.

Presentation:

 Mood: feelings of worthlessness, guilt or suicide

 Sleep patterns: insomnia or hypersomnia
 Weight: increase or decrease
 Cognition: impacts concentration, decision making and problem solving.

Assessments:

 ADLs: consider routines, Bay-Area Functional Performance Evaluation (BaFPE)

assessment of cognitive, affective and performance skills in daily living tasks and social
interaction skills.
 Sleep cycles
 Productivity: roles and interests
 Leisure: roles and interests, interest inventory
 Mood: Beck Depression Inventory
 Cognition: memory, attention, concentration (MMSE, CCT, Cognistat)
 Functional Tasks

Interventions:

 CBT: Focus on changing automatic and negative thoughts to promote positive changes
in thinking and behaviour.
 Interpersonal Therapy: Focus on examining interpersonal relationships and social
supports and building social support networks with the client.
 Goals: focus on establishing hope and goals
 Focus on helping the client to reduce the number and severity of stressors in his/her life
where possible.

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  Re-establish normal routines through scheduling and planning ahead.
 Encourage participation in activity/meaningful occupation as chosen and defined by the
client.
 Modify the environment to promote wellness.
 Explore productivity options – work, education, volunteerism.
 Increase energy and motivation through activity/exercise/recreation.
 Set realistic goals – short term and longer term based on client wishes
 Provide opportunities for success – i.e. make short term goals achievable
 Identify and practice positive coping skills for use in times of stress
 Offer instruction on stress reduction and relaxation techniques
 Encourage interaction with peers and family if possible (develop support networks)
 Practice communication skills such as assertiveness through education and role-playing.
 Provide education regarding the role of meaningful occupation and the environment in
the promotion and maintenance of health

Major Depressive Disorder

‘In its full syndromal expression , clinical depression manifests itself as major depressive
disorder, with episodic course and varying degrees of residual manifestations between
episodes’

Definition: The diagnostic criteria for Major Depressive Disorder (MDD) is defined in the DSM-
IV. MDD is characterized by a depressed mood or loss of interest or pleasure in daily activities,
lasting for at least a 2 week period. MDD represents a change from a person’s normal mood
and can affect sleep patterns (hypersomnia or hyposomnia), weight (increase or decrease in
appetite), concentration, decision making, and problem solving skills. The person with MDD
may feel worthless or inappropriately guilty and may have thoughts of suicide. Function is
disrupted in some, or many, areas of self-care, productivity, leisure, and social roles. Note:
Other types of depression include dysthymic disorder, atypical depression and depression with
psychotic features.

Prevalence: It is estimated that up to 25% of women and 10% of men will experience
Depression in their lifetime.

Cause: The exact cause of MDD has not yet been determined. A mix of genetic, psychosocial,
and environmental factors play a role in its development. Various theories and research
suggest that the dysregulation of neurotransmitters in the brain (including serotonin,

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dopamine, and norepinephrine) are responsible for depressive symptoms. Pharmacological
treatment is based upon this assumption and research.

Course: In 50% of patients the onset of MDD occurs before the age of 40 (although it may occur
at any age). A typical untreated episode of depression lasts approximately six to thirteen
months, while a treated episode can subside as early as three months. As clients experience
more depressive episodes, the time between episodes decreases and the severity of the
episode is likely to increase. The mean number of MDD episodes, per client, over a 20 year
period is 5 or 6.

Assessment:

 Inpatient – Acute. Focus on meaningful occupation and recovery

 Self Care – ADL and ability to function independently, sleep-wake cycle, nutrition
 Productivity and Leisure – Roles, interests and values. Meaningful occupation –
Vocational, educational, volunteer possibilities (if client desires). Role perception, skills,
abilities, aptitudes, goals
 Components – Attention, decision-making, problem-solving, self-concept, self-
confidence, restlessness, agitation, poor endurance, hopelessness, lack of motivation,
suicidal thoughts
 Tools – COPM, Role Checklist, Interest Checklist, Joy List, Observation (i.e., ADL, social
functioning etc.). The BaFPE, the KELS, or another functional assessment may be used
for discharge purposes if the client demonstrates cognitive difficulties or other
significant difficulties that affect independent functioning
 Outpatient – Less acute to chronic. More focus on functioning independently in the
community and setting and attaining goals.

Treatment:

Pharmacological, psychosocial, and occupational therapy treatments have all been linked in the
literature to a decrease in depressive symptoms. There is also evidence that a combination of
drug treatment and psychosocial/occupational therapy treatment is more effective than a
single treatment.

 Pharmacological Treatment: Treatment with medication has been proven to be

effective at decreasing the symptoms of depression. It is used to treat acute depression
and can be used as a prophylactic in an attempt to reduce the number and severity of
episodes experienced by a client. There are various classes of medication used to treat
MDD.

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 o Tricyclic Antidepressants (TCA’s) – Works by increasing the availability of
norepinephrine and serotonin. It is the oldest type of antidepressant still in use
today. Examples – Tofranil, Elavail, Pamelor
o SSRI’s – Selective Serotonin Uptake Inhibitors – Prevent the reuptake of
serotonin presynaptically. Examples - Prozac, Zoloft, Paxil, Luvox, Celexa
o MAOI’s – Monoamine Oxidase Inhibitors – Inhibit the destruction of
norepinephrine, dopamine, and serotonin by monoamines. Used when clients
do not respond to other types of antidepressant medication. Examples – Nardil,
Parnate, Eldepryl
 Psychosocial Treatment: With specialized training OT’s can practice these types of
therapy.
 Cognitive Behavioural Therapy – Focus on changing automatic and negative thoughts to
promote positive changes in thinking and behaviour.
 Interpersonal Therapy – Focus on examining interpersonal relationships and social
supports and building social support networks with the client.
 Occupational Therapy Treatment (inpatient and outpatient):

It is important to help the client to establish hope and goals. Be realistic without being
judgmental. People who have MDD have the potential for recovery, long-term management of
their illness and independent function.

Some treatment approaches:

 Focus on helping the client to reduce the number and severity of stressors in a his/her
life where possible.
 Re-establish normal routines through scheduling and planning ahead.
 Encourage participation in activity/meaningful occupation as chosen and defined by the
client.
 Modify the environment to promote wellness.
 Explore productivity options – work, education, volunteerism.
 Increase energy and motivation through activity/exercise/recreation.
 Set realistic goals – short term and longer term based on client wishes
 Provide opportunities for success – i.e. make short term goals achievable
 Identify and practice positive coping skills for use in times of stress
 Offer instruction on stress reduction and relaxation techniques
 Encourage interaction with peers and family if possible (develop support networks)

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  Practice communication skills such as assertiveness through education and role-playing.
 Provide education regarding the role of meaningful occupation and the environment in
the promotion and maintenance of health.

Eating Disorders

Definitions:

1) Anorexia Nervosa: Refusal to maintain weight over a minimum normal weight for height and
age weight loss of 15% or more of ones original body weight an intense fear of gaining weight
or becoming fat fear that weight gain is out of ones control distorted body image amenorrhea
in women (loss of menstrual periods). 2 Types:

 Restricting type: person is not engaged in binge/purge behavior

 Binge-eating/purging type: person has regularly engaged in binge/purge behavior

2) Bulimia Nervosa: recurrent episodes of binge eating (rapid consumption of a large amount of
food in short period of time) feeling of lack of control over eating behavior recurrent
inappropriate compensatory behavior in order to prevent weight gain (i.e. vomiting, laxatives,
diuretics, enemas, fasting, excessive exercise) cycle occurs at least 2x/week for 3 months
persistent concern with body shape and weight. 2 Types:

 Purging Type: engaged in vomiting or misuse of laxatives, diuretics, enemas

 Nonpurging Type: person has used other behaviors such as fasting, excessive exercise
but not behaviors mentioned above

Assessments:

1) Mental Status Exam: Focus areas for examination include:

 Alertness and Orientation

 Appearance, Attentiveness (Hallucinations)
 Language (speech flow and content)
 Memory
 Perceptions
 Thought processes (coherent or disorganized)

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2) COPM - to determine more specific areas of self care, productivity and leisure that are being
affected due to eating disorder

3) Quality of Life Interview - a structured, 40 min. interview assessing a wide range of life
domains such as; living situation, social relations, leisure activities, finances, safety and legal
problems, work, school and health.

4) Interest Checklists

5) Role checklists - 15 minute, self-report questionnaire focusing on a persons’ occupational

roles based on MOHO frame of reference

6) Occupational Performance History Interview - a 45-60 min., semi-structured, narrative

interview looking at occupational roles, daily routines, activity/occupational choices, critical life
events

Consider: vocational history and interests, level of physical activity, body image, goals and
values, affect or mood, self-concept and self-esteem, social skills and roles.

Intervention:

Intervention is usually part of a team management approach and a lot of the therapy in
inpatient, outpatient and community settings is within a group format*

 Individual/Group Psychotherapy
 Psychoeducation/Skill Training - social skills, assertiveness skills, stress management,
goal setting, Strategies to stop binge/purge cycle, nutritional guidance
 Cognitive Behavioral Therapy - to alter cognitive distortions/thinking and to provide
more positive ways of viewing stressful situations
 Expressive Art therapy - to provide opportunities for mastery, control and self-
expression
 Daily Living Skills
 Vocational Support/Rehab.

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 P

Personality Disorders

Definition: A cluster of disorders that usually begin in adolescent or early adulthood, are stable
over time and lead to distress in the individual or impairment in the individuals ability to work,
engage in leisure, or engage in interpersonal relationships.

Presentation: The major feature of a personality disorder is an enduring pattern of inner

experience and behaviour that deviates markedly from the expectations of the individuals
culture and is manifested in at least two of the following areas: affectivity, cognition, impulse
control, and interpersonal functioning.

Approximately 1-3% of the population is diagnosed with a personality disorder.

 CLUSTER A: Individuals with these disorder appear odd or eccentric (more common in
men)
o Paranoid personality disorder – is marked by extreme suspiciousness and
distrust of others. Attributes hidden motives and agendas of hostility directed by
others toward self. Individual is easily offended, tends to misread and distort
verbal and non-verbal communications, and is hypervigilant.
o Schizoid personality disorder – is symptomatic of individuals who are withdrawn,
introspective, oversensitive, seclusive, and detached from initiating and
maintaining close relationships. Individual tends toward working alone and has
difficulty expressing feelings.
o Schizotypal personality disorder – is characterized by a desire to be alone. The
cognitive style tends to be field independent, where the individual is more
interested in activities involving mechanical tasks, such as computer or
mathematical games. These individuals tend not to have many close friends and
are not usually involved with their families.
 CLUSTER B: Individuals with these disorders often appear dramatic, erratic and
emotional.
o Anti-social or psychopathic – antisocial behaviour such as violence, criminal
activity, physical or sexual abuse, or related behaviours that reflect a lack of
moral and ethical standards. Synonymous terms are sociopathic and antisocial
reaction.
o Borderline personality disorder – inability to discover meaning in one’s life, have
a feeling of emptiness and have difficulty maintaining long-term relationships.

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 Emotional outbursts, sadness, fear, and suicidal ideation are frequently
experienced.
o Histrionic personality disorder – characteristic of individuals who are prone to
exaggerate, act out or demonstrate feelings, and show explosive personality
reactions. They strive for excitement and surprise in relationships with others.
Others characterize these individuals as vain, self-centred, demanding and
shallow.
o Narcissistic personality disorder – individuals show signs of grandiosity toward
self, fantasies of power over others, omniscience, self-importance, vanity, and a
strong need for admiration by others and opportunities for exhibiting self.
Sometimes the individual shows a lack of empathy and understanding toward
others.
 CLUSTER C: Individuals with these disorders often appear anxious or fearful (more
common in women)
o Avoidant personality disorder - social avoidance, lack of friends, inhibition of
feelings, feeling of inadequacy, and hypersensitivity to criticism. The individual
tends to be a loner and does not seek out social groups or friendships.
o Dependent personality disorder – characteristic of individuals who cling to other
individuals, have difficulties making decisions, lack self-confidences, and are
fearful of losing support or approval from others. Tend to be field dependent, in
that they have difficulty being objective about their own personality.
o Obsessive-compulsive personality disorder – can be described as an individual
having a morbid concern with neatness, orderliness, perfection, and ritualistic or
repetitive behaviour. Symptoms include extreme preoccupation with details that
interfere with task completion, excessive time at work at the expense of leisure,
over-conscientiousness regarding ethical or legal standards with regard for
flexibility in decision making, miserly spending attitude and the hoarding of
objects.

Assessments:

1) DSM IV (not to be done by OT but how psych would DX them)

2) COPM

3) Quality of Life Interview: assess life circumstances of individuals with severe mental illness in
terms of their actual experiences and feelings about those experiences. The QOL interview

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assesses a wide range of life domains such as; living situation, social relations, leisure activities,
finances, safety and legal problems, work, school and health.

4) Mental Status Exam: Focus areas for examination include:

 Alertness and Orientation

 Appearance, Attentiveness (Hallucinations)
 Language (speech flow and content)
 Memory
 Perceptions
 Thought processes (coherent or disorganized)

5) Bay-Area Functional Performance Evaluation (BaFPE): assessment of cognitive, affective and

performance skills in daily living tasks and social interaction skills.

Intervention:

NOTE: individuals with personality disorders often try to ‘bend or break the rules’. The
management team must agree on the rules and consistently follow through on carrying out the
rules and their assigned consequences.

Underlying issues to be addressed via OT intervention include

 inaccurate perception of self and others

 inadequate social skills
 poorly developed personal values and goals
 poor self esteem

Main intervention techniques used for individuals with personality disorders

 Group therapy: Main goals include: Instillation of hope in the client, universality of
sharing experiences, imparting of information, altruism, simulate family structure, re-
development of basic social skills, imitative behaviour, interpersonal learning and
catharsis
 Social skills training: develops social skills & networks. Teaches socially acceptable
learned behaviours (skills in attending, listening, conversation, supporting others,
problem-solving & self-control) that enable a person to interact with others and to elicit
positive responses.
 Individual psychotherapy: treatment technique that relies primarily on the verbal
interactions between therapist and client. General phases of psychotherapy include:

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 establishing a therapeutic alliance with the client, understanding the client’s problems
and making a tentative dx, helping the client to understand and gain insight into the
causes of his/her problems, setting goals for tx that are mutually acceptable by therapist
and client, implementing treatment where the client learns and tests out new
behaviours, and closure and d/c of the client.
 Cognitive-behavioural Therapy: application of self-regulation methods and strategies to
change thinking and behaviour. OT is the educator/facilitator within this model.
Principles of CBT include: therapeutic sessions are purposeful and structured for the
client, either in a group or individually, client is an active learner and practices methods
during sessions, new behaviours learned are positively reinforced by the therapist, client
is encouraged to actively practice method as homework and to keep a diary or checklist
of progress, client is given continuous feedback regarding the ability to cognitively
control symptoms and stressors by monitoring physiological responses through
biofeedback, therapist and client establish therapeutic alliance and cooperatively select
activities that increase positive cognitive control of symptoms and stressors by
incorporating copers into a daily schedule of activities, therapist evaluates client’s
progress through self-eval of compliance.
 Medication: as needed to control symptoms experienced which interfere with ability to
function independently

Phobias

Definition: A group of anxiety disorders characterized by intense, irrational fears, either of

particular things or situations, such as snakes, heights, confined spaces, water, or flying (specific
phobias) or of being embarrassed or humiliated in a social setting (social phobia).

Social Phobia: An excessive or unrealistic fear of social or performance situations.

 Typical situations feared or avoided by individuals with social phobia include parties,
meetings, eating in front of others, writing in front of others, public speaking,
conversations, meeting new people, and other related situations.
 Anxiety is not exclusively related to having the symptoms of another medical or
psychiatric condition noticed by others (e.g., a patient with Parkinson’s disease who is
anxious about others noticing a tremor would not be considered to have social phobia).
 Fear must interfere with the individual’s life or be associated with significant distress.

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Specific Phobia: Excessive or unreasonable fear of an object or situation, usually associated
with avoidance of the feared object or situation. Examples include phobias of flying, heights,
animals, injections, and blood.

 Fear must not be related to another disorder (e.g., an individual with agoraphobia who
avoids flying due to the possibility of having a panic attack)
 Associated with significant distress or functional impairment.

Assessments:

Areas:

 Daily living skills

 Productivity values, tasks, and skills
 Leisure interests and skills
 Problem-solving
 Time management
 Role performance and skills
 Social skills

Tools:

1) COPM

2) Role Checklist

3) Activity Configuration

4) Observation of client in vivo looking for somatic and psychological symptoms when exposed
to their phobic situation. Ask client to rate fears using Likert scale. This can then be used as a
baseline measure and can be repeated to measure change as treatment progresses.

Interventions:

Social Phobia

 CBT: exposure to feared situation

 Role playing
 Social skills training

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Specific Phobia

 CBT: exposure to feared object or situation

Schizophrenia

Definition: Characterized by 2 or more of the following symptoms: delusions, hallucinations,

disorganized speech, disorganized or catatonic behaviour, flat affect, alogia, avolitional

 Alogia: impoverishment in thinking as demonstrated in speech and language

 Avolitional: inability to initiate or persist in goal-directed activity
 Delusions: fixed false belief based on incorrect inferences about external stimuli
 Hallucination: sensory perception without external stimuli

Subtypes of Schizophrenia:

 Disorganized Schizophrenia
o Childish behaviours
o Assuming absurd postures
o There is a pronounced incoherence of speech.
o Mood disturbances: flat affect or extreme silliness
o Disorganized behaviour or lack of goal orientation
o May be severely withdrawn
 Catatonic Schizophrenia
o Marked disturbance in motor behavior
o Catatonic stupor or complete immobility, usually accompanied by mutism
o Waxy flexibility: limbs can be moved or arranged by another person. Many
catatonics alternate between periods of immobility and periods of frenzied
motor activity, which may include violent behaviour.
o Catatonic rigidity: Strenuously resist any effort on the part of others to move
their limbs
o Echolalia and echopraxia (imitating the movement of others)
o Catatonic negativism: refuse to do what is requested of them but will
consistently do the opposite
 Paranoid Schizophrenia
o Far more common than either the disorganized or catatonic types

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 o Perform well on cognitive tests
o Healthy pre-morbid life and better long term outcomes

Defining characteristics of paranoid schizophrenia are delusions and hallucinations of a

relatively consistent nature, often related to the themes of persecution and grandeur.

Presentation:

 Self Care: may be indifferent towards ADLs, eg. Grooming

 Productivity: limited work skills
 Leisure: limited interest
 Sensorimotor: poor gross motor skills, repetitive behaviours (rocking or pacing),
perceptual issues (figure-ground), tardive dyskinesia (repetitive, purposeless,
involuntary movements)
 Cognition: easily distracted, decreased level of arousal, dividing attention, difficulty with
concept formation, difficulty following time schedule
 Psychosocial: blunted affect, poorly defined self-concept, poor verbal and non-verbal
communication skills.

Assessment:

Areas to consider:

 Daily living skills

 Productivity: experience, skills and interests
 Leisure: interests and skills
 Physical: postural control, balance, gross movement patterns, stereotypical behaviours,
sensory awareness
 Cognition: safety awareness, problem-solving and decision making, reality testing,
orientation
 Psychosocial: coping skills, social skills, available supports

Assessment Tools:

1) COPM

2) Bay-Area Functional Performance Evaluation (BaFPE): assessment of cognitive, affective and

performance skills in daily living tasks and social interaction skills.

3) Allen Cognitive Level Test

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4) Test of Visual-Perceptual Skills

5) Self-Efficacy Gauge

6) Social Network Map

7) Role Checklist

8) Stress Inventory

9) Motor-Free Visual Perceptual Test

Intervention:

 Self-Care: develop routines, include praise and reward system

 Independent Living Skills: skills training for meal prep, shopping, money management,
public transportation
 Productivity: explore vocational interests, supported employment model
 Physical: exercise program for increased motor control
 Cognitive: provide visual cues
 Assertiveness training
 Social skills training

Substance Abuse

Definition: Drug or alcohol abuse that leads to clinical impairment or distress. Failure to fulfill
major role obligations at work, home or school. Recurrent substance abuse in situations that
could result in harm, such as driving. Legal problems, such as arrests. Social and interpersonal
problems exacerbated by substance use. Substance dependence: repeated self-administration
that results in tolerance, withdrawal and compulsive behaviours.

 Substance intoxication: development of reversible clinically significant changes

(belligerence, cognitive impairment etc)

Assessments:

Areas to consider:

 Daily living skills

 Productivity history
 Leisure interests

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  Physical fitness, endurance and appearance
 Fine motor coordination, manipulation and dexterity
 Cognition: attention, memory, concentration, orientation, ability to follow instructions,
organizational skills, problem solving, learning skills, judgement and safety awareness
 Mood
 Self-concept
 Self-control
 Social skills, communication

Assessment tools

1) COPM

2) Bay-Area Functional Performance Evaluation (BaFPE): assessment of cognitive, affective and

performance skills in daily living tasks and social interaction skills.

3) Test of Visual-Perceptual Skills

4) Self-Efficacy Gauge

5) Social Network Map

Interventions:

 Stages of change
 CBT
 Routine: establish daily routine for self-care
 Life Skills: work on skills that client may not have (meal prep, community transportation,
money management, etc)
 Vocational: skill development, job searching, work hardening, supported employment
 Leisure: identify leisure activities that occur during the time substance use typically
occurs
 Fitness: increase ROM, strength, flexibility, coordination, dexterity
 Cognition: work on activities that involve building a sense of mastery and increasing
concentration, for example crafts
 Anger management
 Group discussions and social interaction

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PREPARING FOR AN OT INTERVIEW

Most OT job interviews are largely behavioral descriptive and scenario based interviews. There
might also be questions to gauge your future expectations, what assessments you have used
and/or what you know about the employer.

There are a lot of practice questions on the web, here is a link to some:
http://www.quintcareers.com/sample_behavioral.html. Go through the questions and answer
them and review them prior to your interview so they are fresh in your mind. This information
is used by recruiters in Alberta, Ontario and British Columbia.

The above link mentions the STAR technique which is great for outlining your answers.

 S-Situation: Present a recent challenge you were faced with

T-Task: What were you expected to achieve?
A-Action(s): What did you do? Why did you do it? What were the alternatives.
R-Result(s):What was the outcome? Did you meet your objectives? What did you learn
from the experience?

 Sample behavioral descriptive questions: (Here are just a few you may be asked.)
o Describe a situation in which you were able to use persuasion to successfully
convince someone to see things your way.
o Describe a time when you were faced with a stressful situation that
demonstrated your coping skills.
o Give me a specific example of a time when you used good judgment and logic in
solving a problem.
o How do you organize yourself?
o Give me a specific example of a time when you had to conform to a policy with
which you did not agree.

Scenario based questions will vary depending on the area you may be applying to. An exam of a
pediatric scenario is listed below and one in which you would expect with no trick questions.

 How would you approach a referral for an 8 year old boy who has been reported to be
move around a lot in his seat, teacher says he presses really hard when printing and he
bothers others in class moving to front of the class?

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 o The employer is looking for observation, talking with parents, teachers,
assessments etc. Rule out other health issues. Talk about time of day, when is it
worse or better. Clinical reasoning and organization.

In general when you get a call for an interview either over the phone or in person make sure
you:

 Re-read the posting carefully. Look for areas that you might not understand completely
or that seem vague. Plan to ask questions in the interview that clarify this information.

 Call the person who scheduled your interview and ask for any information she can
provide about the position and/or department that is additional to what is provided on
the posting. Read this information as carefully as you did the posting. *If you are able to
before your interview, if not, these are questions you can ask the hiring Manager when
she asks if you have any questions, typically at the end of the interview (that may not
have already been covered during).

 Go to the company website ie) www.albertahealthservices.ca and find any information

you can about the program/department for which you are being interviewed. (Great to
be informed).

 Check the prospective employer “Careers Site” to see if the occupation/profession has
been profiled (look under the tab: "Career Profiles").

 Prepare a list of questions that will demonstrate the depth of your understanding of the
position and that will help you to make an informed choice if the position is offered to
you (3-4 well thought-out questions is enough). A job interview is a conversation that
allows both parties to gather enough information to determine whether you are a good
match for the position and whether the position is a good match for you.

 Take your time. Don't be afraid to pause before answering and ask for clarification if you
don't understand the question. Be thoughtful and ask intelligent questions to ensure
you understand what is being asked. If you're uncertain whether your answer provided
what the interviewer was asking, feel free to ask, "Did I understand the question
correctly?" (or your own words that are comfortable for you).

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 Be on time (10 minutes before the scheduled time is adequate, prepared and by the
phone) and give generously of your time if the interviewer/s want to continue the
interview beyond the scheduled time frame.

 Each interview is roughly 45 minutes to 1 hour.

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CAOT NATIONAL EXAM STUDY TIPS

Format:

 200 multiple choice questions

 The candidate is presented with a case study and then several multiple choice questions
follow

Time for writing:

 Two, 2 hour papers

 8:00-10:00 ~ break ~ 11:00-1:00
 Approximately 30 case studies with 200 questions = 50 questions/hr

Content:

 Exam attempts to reflect current OT practice in Canada

 Certification Exam Committee makes up and regulates questions for the exam
 Entry level materialCertification Exam Re)

Study Guide:

 No Canadian study guide available, U.S. study guides available

 Advised to study material form OT courses
 CAOT Exam Resource Manual (download from CAOT)
 Sample questions are in the Resource manual
 *It is strongly recommended that all candidates read the Profile of Occupational
Therapy in Canada to find out the current expectations of the profession in Canada
(download form CAOT)

Scoring:

 Receive results 6-8 weeks after the exam.

 290 = passing score for July 2014 exam (A candidate needs to answer 65% of the
questions correctly).
 Equating places tests scores from different exam administrations on a common scale.
 All exam results are final and cannot be appealed.
 All unsuccessful exams are hand-scored a second time to ensure accuracy.
 At least 95% of graduates pass on their first try.

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Sample Study Method:

Study the following for each area as it relates to OT:

a. Definition (i.e. cause, anatomy, physiology)

b. Assessment (i.e. standardized, non-standardized, “normal” function)
c. Intervention (i.e. environmental modifications, goal setting, models of service delivery)
d. Evaluation (i.e. outcome measures, effectiveness of treatment)

Study Timeline:

CRAM SCHEDULE: 3hours per day, 5 days per week

Week 1 – adult

Week 2 – mental health, peds

Week 3 – professional issues (i.e. COTO, research)

Week 4 – review

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General Study Tips:

TIPS FOR MULTIPLE CHOICE EXAMS

Do’s

a. Read each question carefully, try to understand what the question is asking.
b. Circle or underline key words in the question.
c. Try to understand the answer, not just “recognize” it.
d. Rephrase the question in your own words.
e. If you are not sure how to answer a question, put a question mark beside it and come back.
f. Cover the answers. Try to answer questions before looking at the answer.
g. Cross out wrong answers to eliminate choices.
h. It is “okay” to change your answer. The majority of changes are from wrong to right. Our
first impressions and immediate impulses often need to be corrected on second thought.

Don’ts

X Don’t select an alternative just because you remember learning the information in the
course; it may be a “true” statement in its own right, but you have to make sure that it is the
correct answer.

X Don’t pick an answer just because it seems to make sense. You are answering from your
knowledge of the course content, not just from your general logic.

X Don’t dismiss an answer just because it seems too obvious and simple. If you are well
prepared for the exam, some questions will appear straightforward.

X Don’t be wowed by fancy terms i.e. that sounds impressive, it must be right.

X Don’t pick “c” every time you are unsure of the answer.

X Don’t pick your answer based on patterns of response i.e. it can’t be “b” we just had 3 in a
row.

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TIPS FOR REDUCING STRESS:
 A stressful situation can trigger a train of thought “spiral of anxiety” which can break
your concentration. Try pushing your chair back a bit, take a few deep breaths, and
concentrate on relaxing muscles in your body (i.e. hands, arms shoulders, etc.).
 Practice talking yourself down from an anxiety spiral when preparing for the exam so
you can do it if one occurs during the exam.
 Make a checklist of topics you will study or keep a log or calendar to record your study
periods. Review it before the exam to reassure yourself you are well prepared.
 Everyone gets anxious about exams, which could be a good thing. Hormonal releases in
response to anxiety give special reserves of energy in exam situations so you can sit and
concentrate for extended periods of time.
 Know your frames of reference.
 Watch specific wording. They is usually two possible answers and clinical reasoning will
be your asset.

Practicing After the Exam:

 In most provinces you can practice using a Provisional Practicing Certificate while you
wait to write the exam.
 Must obtain an Employment Acknowledgement Form.
 A Provisional Practicing Certificate will expire 60 days after the first available exam date
after you register.

Unsuccessful Results:

 Unsuccessful exam candidates may re-write the exam at any subsequent sitting.
 CAOT will automatically send you exam registration information so you can register for
the next available exam sitting.
 There is no limit to the number of times you may write the exam.
 You need to contact the college and notify them of failure. They will extend the
Provisional Practicing Certificate until 60 after the next exam date. If you fail a second
time your Provisional Practicing Certificate can no longer be extended as per college
bylaws.

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SAMPLE CAOT EXAM QUESTIONS

* Questions taken from national questions, BC and Ontario Associations. Many questions are
similar to those found in the July 2014 exam. In other cases, some questions are much harder
than the national exam.

1. An OT working in private practice receives a phone call from a lawyer who represents a
previous client. The lawyer requests a copy of an assessment report prepared by the OT
three months ago concerning the client. Which one of the following is the MOST
appropriate course of action for the OT?

a. Inform the lawyer that the report cannot be released without the consent of the
physician.
b. Inform the lawyer that the report can only be released to the client.
c. Inform the lawyer that the client’s assessment report belongs to the physician ans
suggest the lawyer call the physician.
d. Inform the lawyer that the report will be provided after receipt of verification that
the lawyer is the legal representative of the client.

2. An OT is providing direct clinical care in a long term rehabilitation setting for a 20 year old
male patient who has a spinal cord injury. All of the following actions could be
considered sexual abuse under the Regulated Heath Professions Act EXCEPT:

a. Hugging the patient to say goodbye after the course of treatment.

b. Discussing the best way for the patient to apply a condom.
c. Developing a consensual sexual relationship with the patient.
d. Flirting with the patient in order to establish rapport.

3. An occupational therapist consults to the residents of a nursing home. The OT records of

care are integrated within the complete health care record held by the nursing home.
The nursing home keeps the records for fewer than 10 years according to the legislation
under which they operate. Which statement BEST represents what the therapist is
required to do?

a. Nothing. Legislation takes precedence over the Practice Guideline: Client Records.
b. Make copies of all OT service records and hold them for 10 years as per the Practice
Guideline: Client Records.
c. Arrange with the nursing home to hold the OT service records for 10 years.
d. Resign his/her position and discontinue service to the nursing home.

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The following vignette pertains to questions 4-9.
Mr. Virginia is 56 years old, widowed a year ago and living with his daughter, his son and his
son’s’ family in an apartment. Currently, he is being treated at Sunnybrook Hospital due to
severe pneumonia. Occupational therapy treatment focused on reducing the potential risk of
falls, improving limited ROM in bilateral shoulders and addressing overall general safety
concerns. On the first day of treatment, he was adamant about not participating in treatment
and stated that he wanted to “go home and continue his job as a packer” in a food
manufacturing company. His doctor advised him that he will not be physically able to return to
work, and that he should stay away from animal fur to decrease his risk of infection. Mr.
Virginia has indicated to the therapist that he plans to return home to his family and cat,
despite his doctor’s advice.

4. The occupational therapist wants to determine Mr. Virginia’s personal treatment goals.
Which of the following would be most appropriate?

a. Social Network Mapping

b. Role Checklist
c. PEO
d. COPM
e. OPHI

5. Mr. Virginia’s family has approached you and said that they are looking for a suitable
nursing home that will provide him with the best care. The occupational therapist
should:

a Discuss Mr. Virginia’s preference to the multidisciplinary team.

b Set up a meeting with Mr. Virginia and his family to discuss discharge planning.
c Inform Mr. Virginia’s family that he plans to go home.
d Inform Mr. Virginia that his family cannot take care of him, and talk to him about a
nursing home that you feel he will really like.
e. Continue therapy and don’t get between Mr. Virginia and his family.

6. During a therapy session, Mr. Virginia confesses to the therapist that his goal is to return
to work as a packer at the food manufacturing company. The first thing the
occupational therapist should do is:

a. Explain to Mr. Virginia why he can’t return to his job.

b. Suggest an alternative vocation after administering the Interest Checklist.
c. Call his employer to conduct a worksite evaluation.
d. Assist Mr. Virginia in finding a volunteer position that he enjoys.

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 e. Ask Mr. Virginia why he wants to return to his previous job and discuss supports and
barriers within that work environment.

7. Mr. Virginia reports that he does not want to give away his cat because it is the only pet
he has. Using a client-centered approach, the occupational therapist’s initial approach
would be to:

a. Advise Mr. Virginia to give away his cat.

b. Educate Mr. Virginia about safety precautions that may permit
him to keep his cat.
c. Talk to Mr. Virginia about other possible house pets that would
reduce his risk of infection.
d. Talk to his physician about what he has told you.
e. Investigate options where he could visit his cat at a friend or
family member’s place.

8. Following discharge, the occupational therapist wishes to determine if therapy has been
effective in assisting Mr. Virginia. If the therapist employs the naturalistic inquiry
method to find out client outcomes, the therapist will use:

a. Both subjective and objective measures of effect.

b. The Functional Independence Measure.
c. Statistical analysis.
d. Feedback from the client and his family.
e. Client satisfaction questionnaires.

9. The first thing the occupational therapist will do as part of treatment includes educating
Mr. Virginia about:

a. Environmental adaptation
b. The level of functional performance he needs before discharge is possible
c. The importance of participating in exercise so that he can improve his shoulder ROM
and reduce his risk of falling
d. The role of the occupational therapist
e. Hospital policies regarding quality of care and patient feedback

10. An OT has been providing services in a client’s home. During the last few visits, the
client has become increasingly argumentative and challenging the OT role. During the most

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 recent visit the client became very angry with the OT and then became verbally aggressive.
The OT felt threatened and responded angrily by yelling at the client, abruptly ending the
session and slamming the door when leaving. Which one of the following describes how the
college would view this situation?
a. The client and therapist are equally at fault for their behavior
b. The client has been abusive toward the OT
c. The client’s actions absolve the OT of any possible claims of professional misconduct
of the OT
d. The OT has behaved in a manner that could be considered an act of professional
misconduct.

11. Which one of the following is the MOST appropriate subsequent action by the OT?

a. Apologize to the client and discuss with the client how such situations can be
avoided in the future.
b. Explain to the client that the therapeutic relationship has been eroded, refer the
client to a colleague and discharge the client from the caseload.
c. Ask the client for an apology prior to resuming treatment.
d. File a charge against the client.

12. An OT works for a private rehabilitation company. Reports are usually completed by the
OT and sent to head office for review by supervisory staff. The supervisor may make
some changes and apply the OT’s signature stamp prior to distributing the report. What
statement describes the BEST procedure for the OT to follow in this setting?

a) never allow the supervisor to apply your signature stamp.

b) Arrange to review any changes at a later date. Send an addendum to the report if
necessary.
c) Nothing, this meets company policy and is standard practice.
d) Arrange to approve any changes prior to the supervisor applying the OT’s signature

13. You are working with a client with a C-6 spinal cord injury. As you bring him to standing
in the standing table, he complains of dizziness and nausea and seems to be losing
consciousness. Your best course of action is:

a. Wait, the symptoms should pass as tolerance increases.

b. Bring him down to the wheelchair again.
c. Call for his nurse.
d. Bring him down to the wheelchair, and then immediately recline him.

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The following vignette applies to questions 14-20:

Mr. R. is a 58 Year old who suffered a right CVA with resultant left hemiplegia. He is currently a
client at a rehabilitation center. At present his left upper extremity is in total flexor synergy.
During treatment he understands instructions and is able to follow 3 step commands.
Difficulties are noted with self-care tasks, especially drooling during mealtimes. He is able to
propel a wheelchair but consistently slides out of it and drives it into walls and doors located on
his left side.

14. The primary reason for the client’s difficulty in driving his wheelchair is:
a. Left retinal neuropathy
b. Ocular motor nerve impairment
c. Decreased use of visual scanning
d. Left break applied
e. Left optic nerve impairment

15. Using Bobath’s Neurodevelopmental approach, an occupational therapy upper limb-

retraining programme for Mr. R would initially consist of:
a. Resistive exercise
b. Splinting in position of function
c. Positioning and weight bearing
d. Passive range of motion
e. Facilitating extension synergy

16. Which of the following activities would best facilitate elbow and shoulder extension for
Mr. R?

a. Playing wall checkers with the board at waist level, placing the capture checkers in
his lap.
b. Wheelchair hockey holding the stick with an adapted grip device
c. Dressing training, using one-handed techniques.
d. A pegboard game, positioned to his right at shoulder level and the discarded pegs on
the left by his feet
e. Cooper tooling while seated at a workbench.
17. During mealtimes, Mr. R. was observed to consistently make no attempts to clear
pocketed food from his mouth or wipe food drooling from the left side of his mouth. The most
likely reason for this is:

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 a. Poor food placement.
b. Decreased oral motor control
c. Left hemianopia.
d. Decreased oral facial sensation.
e. Decreased cognitive function.

18. Mr. R consistently slides out of his wheelchair despite wearing a lap belt. Using
biomechanical principles, this can be corrected by:
a. Placing a wedge under his left hip
b. Placing a pillow against left side of the trunk
c. Raising foot pedals to increase hip flexion
d. Providing a lap tray
e. Providing a countered wedge cushion with a firm flat base

19. Despite frequent remainders regarding safe transfers, Mr. R. has fallen numerous times.
What could be the primary reason for this?
a. Decreased sensation
b. Decreased proprioception
c. Impulsive behavior
d. Memory loss
e. Visual difficulties

20. In the occupational therapy department, Mr. R. has chosen to do a painting activity. The
therapist places the easel in front of him and the paints to his left side. What goal is being
achieved?
a. To improve his skills in one handed activities
b. To increase his concentration span
c. To develop his communication skills
d. To increase his visual scanning skills
e. To provide a medium for self-expression

The following vignette pertains to questions 21-27.

Mr. C is a 50 year old, single unemployed cement finisher who sustained a bimalleollar fracture
of the right ankle nine months ago. The fracture was treated by closed reduction and a below

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knee cast for three and a half months. He is plagued by joint stiffness, chronic swelling and
weakness of all ankle muscles. He has been unemployed for the past year.

Following six weeks of treatment, ankle swelling has subsided; strength, ROM and tolerance to
weight bearing have improved.

21. Methods of treating a chronic swelling would be provision of:

a. A regimen of frequent rest.

b. A stool for elevating the foot
c. An elastic stocking and active exercise program
d. An elastic stocking and maintenance of an elevated position.
e. Corrective shoes and an active exercise program

22. From a biomechanical standpoint, which of the following activities would not be
considered?
a. Precautions and contraindications for weight bearing tolerance
b. Grading the activity for: strength, active ROM and endurance
c. Positioning the patient in relation to the materials
d. Adapting activities to progress patient to next level of motor control
e. Stabilization needed to do the activity

23. After therapy, the only residual deficit is joint stiffness. Your next goal would be to
increase:
a. Standing tolerance
b. Endurance to work related tasks
c. Tolerance for climbing
d. Co-ordination and balance
e. Avocational and leisure pursuits

24. You wish to determine Mr. C’s ability to return to similar employment. The most
appropriate step in evaluation would be:
a. Work sample assessment
b. Job analysis
c. Vocational interest inventory
d. Work simulation
e. Prevocational evaluation

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 25. Your treatment team is meeting with Mr. C to discuss his discharge and long term goals.
Which of the following resources would be the most appropriate to include in this discharge
plan
a. Social service agency
b. Vocational rehabilitation service
c. Physical therapy
d. Day therapy program
e. All of the above

26. To meet the treatment goal of increasing Mr. C’s ankle dorsi and plantar flexion, which
of the following activities would be the most appropriate?
a. Playing floor checkers
b. Using a pottery kick wheel
c. Cutting with a treadle saw
d. Climbing ladders
e. Standing during woodworking

27. When setting up Mr. C’s treatment plan, which of the following would be of LEAST
consideration?
a. Patient’s interest
b. Psychological attitude
c. Feelings of self worth
d. Family relationships
e. Previous employment

28. A therapist in private practice in the community arrives to visit a client and sees through
the screen door that the client is lying on the floor just inside, apparently unconscious.
She reaches for her cell phone to call for help and the client rouses to clearly say, “go
away” and then lapses back into unconsciousness. What is the BEST course of action for
the therapist to take?

a. Assess the client’s capacity to make the decision regarding seeking medical help and
then decide what to do.
b. Call the office to have someone check the file, and determine if the client signed an
advance directive covering this situation.
c. Leave immediately to comply with the client’s wishes.

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 d. Initiate emergency care, as consent is not required.

29. An OT who has worked in pediatrics for many years has decided to take a position
working in a general adult medicine department at a local hospital. Which one of the
following is required to meet professional responsibilities?

a. Arrange to complete a clinical placement in general adult medicine in order to

become familiar with current theory, techniques, and general practices of other
therapists working in that field.
b. Consult with other OTs and become familiar with the College Standards of Practice
as they specifically apply to general adult medicine.
c. Arrange for clinical supervision and become familiar with current theory, techniques
and general practices of other therapists working in that field.
d. Consult with physicians working in adult general medicine concerning how to
become best familiarized with current theory and techniques.

The following vignette pertains to questions 30-36.

JR is 19-year-old senior in high school was involved in a high-speed motor vehicle accident. A CT
scan showed multiple contusions in both frontal lobes, as well as in the right fronto parietal-
temporal region.
During his intensive care stay, JR suffered from intracranial pressure, secondary to edema
and multiple infections. He first showed signs of arousal - spontaneous eye opening and
tracking people in his room - 27 days after the accident, and followed his first 35 days after
injury.
He was transferred to inpatient rehabilitation where he presented with poor attention,
agitated behavior, and left hemiplegia. He required assistance with self-care activities, mobility
and leisure activities.
When he made transition to outpatient therapies, he was independent in basic self-care, and
able to initiate and participate in other activities with minimal assistance. He continued to
experience difficulties in higher cognitive functions and had diminished use of left upper
extremities.
Currently, JR is in outpatient therapy. He becomes easily frustrated and states he feels as if
"life has gone on without him." The therapist is helping JR to set realistic goals in terms of
education and vocation as well as advanced ADL's within home and community. But JR listened
in disinterested silence and any mention of developing goals by the therapist caused JR to
become angry. The therapist tried to encourage JR by describing about groups of outpatient
coming in for leisure interest and social networking and involvement in volunteer work.

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30. At the discharge meeting, the therapist described his lack of success in JR's case, this
could be due to:

a. therapist unrealistic treatment goals

b. JR's lack of motivation
c. JR's and the therapist differing views about work, productivity and leisure
d. Therapist poor evaluation
e. Therapist failure to assess JR's goals and priorities

31. The therapist is helping JR to set realistic goals in terms of vocation and ADL is an
example of which type of reasoning in action?

a. Pragmatic
b. Procedural
c. Interactive
d. Conditional
e. Narrative

32. To determine JR's level of interest and desire to participate in interests in the future, the
therapist should use what assessment instrument?

a. Canadian Occupational Performance Measure

b. NPI interest Checklist
c. Occupational Self-Assessment
d. Occupational Questionnaire
e. Kohlman Evaluation of Living Skills

33. JR's manifestation in the inpatient rehabilitation signify what level of Rancho Los Amigos
Scale?

a. Confused Appropriate
b. Localized response
c. Confused, Inappropriate, Nonagitated
d. Confused Agitated
e. Automatic Appropriate

34. Which assessment would the occupational therapist choose to get a global
understanding of what is important to JR?

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 a. Role Checklist
b. Learner Collage
c. Interest Checklist
d. Leisure Inventory
e. Assessment of Motor and Process Skills

35. The therapist missed part of JR story, as the result of the treatment wasn't a success.
The therapist could have elicited some cues to clarify JR's case if he:

a. Used more valid and reliable tests of occupational performance

b. Used an interactive and collaborative type of reasoning and approach
c. Identified JR's diagnostic related problem with his routine life
d. collected data from other sources than JR
e. focused more on realistic goals.

36. JR signifies his intention and interest to return to work in his previous part-time
occupation. The logical first step is to:
a. conduct a prevocational evaluation
b. establish work tolerance
c. perform a job analysis
d. conduct a vocational interest inventory
e. evaluate occupational roles

The following vignette pertains to questions 37-44.

Mrs. H. is a 39-year old, married woman, living with her husband and three children. During the
initial interview, Mrs. H. is cooperative and pleasant and she is able to talk about herself. This is
her first contact with a mental health center.

Mrs. H. states she is seeking help at this time because she is experiencing increased fear that
she would not be needed once her children leave home. She describes an inability to ask for
attention and support in a direct manner, feeling at times that her husband and children do not
appreciate her. Her self-esteem is low, and she can never find time to complete her work as a
seamstress. All major decisions in her family are made by her husband. The youngest of five
children, she always felt lonely and like an outsider, and now has very few friends. She
describes her marriage as comfortable, yet adds that her husband is “boring”, and not able to
address her emotional needs.

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37. The OT wishes to initiate her interaction with Mrs. H. using an assessment of occupational
performance areas which will be client-centred. Which of the following will be most
appropriate?

a. Kohlman Evaluation of Living Skills

b. Functional Independence Measure
c. Bay Area Functional Performance Evaluation
d. Canadian Occupational Performance Measure
e. Role Checklist

38. The OT agrees to help Mrs. H. with time management. What is the most important principle
in time management?

a. Work on the easier goals first to ensure success

b. Rate goals in order of priority
c. Analyze task performance
d. Create a list or appointments
e. Take responsibility for all goals

39. Mrs. H. identifies problems in her communication style, e.g. total avoidance of conflict.
What would be the most appropriate therapy to help her overcome this problem?

a. Family
b. Assertiveness
c. Behaviour
d. Cognitive
e. Reality

40. An activity which may prove helpful in exploring Mrs. H.’s self-esteem/self-image issues
would be:

a. Role playing
b. Autogenesis
c. Refuting irrational believes
d. Self-hypnosis
e. Use of projective techniques

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41. The OT referred Mrs. H. to a group for women who are returning to the work force. The
primary objective in sending her to the group would be to gain:

a. Support and encouragement from other women

b. A new perspective on her role in the home
c. Technique for re-entering the work force
d. New community contacts
e. Assertive strategies

42. Mrs. H. husband called in great distress because his wife was late returning home. He
demanded to know what her treatment consisted of. What should the OT do?

a. Tell her husband to attend the next session

b. Refer him to his wife’s attending physician
c. Ask the husband the reason for his distress
d. Carefully explain her program
e. Encourage the husband to discuss her program with his wife

43. Upon terminating treatment, which response would you most expect from Mrs. H.?

a. No reaction
b. Mood swings
c. Anger
d. Acceptance
e. Anxiety

44. Following discharge the OT wishes to find out if therapy has been effective in assisting
Mrs. H. If the therapist employs scientific and systematic methods to determine client
outcomes, the therapist will use:

a. Client self-reporting questionnaires and interviews

b. Standardized, valid and reliable measurement approaches
c. Feedback from the client and family regarding function
d. Family reporting and client observation
e. Both subjective and objective measures of effect

The following scenario pertains to questions 45 and 46.

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The College has received an inquiry about an OT working as a psychotherapist for a community
mental health agency. The caller wants to know if OTs are allowed to call themselves
psychotherapists.

45. Which one of the following responses would the College be obligated to in response to
the inquiry?

a. The scope of OT practice is flexible. Since psychotherapy is not on the list of

controlled acts, an OT with sufficient training may offer this service.
b. The role of an OT is defined by the Scope of Practice. Psychotherapy is not defined
within the scope of practice so an OT should not be doing this.
c. The scope of OT practice is flexible. Psychotherapy is a apecialized technique,
therefore the OT must also be registered as a psychotherapist in order to provide
this service.
d. The role of an OT is defined by the Scope of Practice. This Scope of Practice allow
for psychotherapy, provided the OT has the appropriate supervision by a qualified
psychotherapist.

46. Which one of the following statements would the College also be obligated to make?

a. OTs who specialize in an area of practice must hold and display a certificate of
qualification.
b. OTs are allowed to represent themselves as specialists in a given area of practice if
they have specialty training and skill in a particular area.
c. OTs are not allowed to represent themselves as specialists in any area of practice,
since the training programs in occupational therapy do not provide sufficient depth
in specialty areas.
d. OTs are not allowed to represent themselves as specialists in any area of practice,
even if they have specialty training and skill in a particular area.

The following situation pertains to questions 47, 48 and 49.

An OT has inappropriately touched a patient the patient tells her psychiatrist, who writes a
mandatory report and sends it to the College of OTs of Ontario.

47. Which of the following MIGHT NOT be included in the mandatory report:

a. The patient’s name

b. The name of the OT being reported.
c. The basic nature and circumstances of the sexual abuse being reported.

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 d. The name of the psychiatrist making the mandatory report.

48. When the College receives the written mandatory report the College would be obliged
to

a. Contact the patient and ask them to try to settle the issue directly with the
therapist.
b. Encourage the patient to make a formal complaint, which is required in order for the
College to investigate.
c. Direct the patient to see a lawyer so that the lawyer can properly prepare the
required formal complaint.
d. Investigate the circumstances set forth in the mandatory report unless it is
impossible to do so.

49. The following are all possible outcomes of an investigation and resolution of the
mandatory report EXCEPT:

a. the registrant could be found guilty of professional misconduct for sexual abuse and
lose their certificate of registration for 5 years.
b. The registrant and the patient could participate in mediation, or alternate dispute
resolution to settle the dispute.
c. The patient could be granted access to the sexual abuse counselling fund and the
costs could be allocated to the therapist found guilty of abuse.
d. The investigation could determine the there are no grounds for the allegation of
sexual abuse.

50. Choose the item that does not describe normal developmental expectations for an 8
year old.

a. project level play is preferred (usually children < 8yrs)

b. Deductive reasoning is possible
c. Playing dress up is a favoured activity
d. Has the ability to perceive and organize information

51. Inflammation of the common extensor origin of the forearm extensor musculature may
result in:

a. gamekeeper’s thumb

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 b. Golfer’s elbow
c. Tennis elbow
d. Pitcher’s shoulder

52. An OT using the psychoanalytic frame of reference suggests kneading dough to make bread
as an activity for a nonverbal and angry patient. The OT is basing her activity choice on
which of the following concepts?

a. Acting out
b. Sublimation (healthy rechanneling of libidinal and aggressive drives into constructive
activity)
c. Identification
d. Regression

53. An occupational therapist works in an institution as part of a multidisciplinary team.

Each discipline contributes information on the client’s progress during weekly rounds.
One person records the information on behalf of the team for the health record. What
statement BEST represents the action the OT is expected to take?

a. Review each progress note for accuracy. Sign only if the OT makes corrections.
b. Sign only when it’s his/her turn to record the progress note.
c. Write his/her own progress notes on the record in addition to the team progress
note.
d. Review, make any needed changes, and sign each team progress note.

54. An OT working in an institution receives a request from a client for access to the OT
portion of the their health record. The institution has a policy that such requests must
be accommodated through health records. Which statement BEST describes the
response the OT would be expected to make?

a. Accompany the client to Health Records and facilitate access to the record.
b. Explain the facility’s process for obtaining the information and offer to discuss the
OT information.
c. Photocopy the OT records for the client.
d. Inform the client that you are unable to help them, as the institution holds the
record.

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55. An OT is contracted by an insurer to complete a client assessment and provide a written
report with recommendations. Written consent for assessment and release of the
report is obtained at the beginning of the first visit. Following the assessment, the
therapist shares the results and recommendations with the client. The client disagrees
with the recommendations and asks the therapist not to send the report to the insurer.
What statement BEST describes what the OT should do?

a. Release the report. The client already provided written consent.

b. Release the report after changing your recommendations.
c. Do not release the report.
d. Release the report. It belongs to the insurer, not the client.

56. Degenerative disorders commonly associated with depression, dementia, and psychosis
include all of the following except:

a. Parkinson’s disease
b. Huntington’s disease
c. Wilson’s disease
d. Connective tissue disease

The following situation pertains to questions 57-62.

Robert was born prematurely, weighing 4 pounds and 3 ounces. He needed a respirator and
ventilator to help him breathe. He also developed many other problems related to his
premature birth. Robert’s mother was told that he would catch up in two years. Robert’s
progress remained extremely slow and at age 15 months he was diagnosed with CP.

57. Six-month-old child’s symptoms such as abnormal muscle tone, delayed or exaggerated
reflexes, postural abnormalities and delayed motor development are signs of.

a. nothing to worry about, some six months old children are like that
b. autism
c. mental retardation
d. Cerebral Palsy
e. Down Syndrome

58. All of the following are clinical symptoms of spasticity except:

a. stretch reflex
b. clonus
c. atrophy
d. hyperactive tendon tap

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59. The technique most commonly used for children with CP is NDT. Which is false
concerning NDT theory?
a. abnormal muscle tone affects muscle, but not feeding, speech or perception
b. NDT uses key points of control to facilitate targeted movements and inhibit other
unwanted movements
c. Change in motor patens results from the individual feeling more normal movements
d. An interdisciplinary effort achieves the optimal gains for the individual
e. NDT emphasizes normalizing muscle tone, inhibiting primitive reflexes and
facilitating normal postural reactions through the developmental sequences.

60. The most common classification of CP is:

a. Spasticity
b. Athetosis
c. Flaccid
d. mixed
e. ataxia

61. What is the most common medical complications related to prematurity

a. bronchopulmonary dysplasia
b. retinopathy
c. intraventricular hemorrhage
d. periventricular leukomalacia
e. Post Hemorrhagic Hydrocephalus

62. As premature is considered every child born before:

a. 37 weeks
b. 39 weeks
c. 40 weeks
d. 41 weeks
e. 36 weeks

The following situation pertains to questions 63-67

A study investigated the effects of two training programs on the body concept development of
preschoolers as reflected in human figure drawings. This study tested the following hypothesis:
a program of sensorimotor activities will be more effective in promoting body concept

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development, reflected by larger score gains on the Goodenough-Harris Drawing Test, than will
a body-part identification program. In other words, vestibular-kinesthetic and tactile input are
presumed to be more basic to body concept development in children than cognitive-perceptual
input.

Twenty-four, three, four and five year old preschool children were randomly divided into two
experimental groups and one control group, after being matched closely by age and sex. All
subjects were pre-tested with the Goodenough-Harris Drawing Test and post-tested with the
same instrument after a one-month intervention training period. Group A received ten hours of
sensorimotor training and Group B received ten hours of verbal body-part identification
training. Group C was not involed in specific training activities during the intervention period.
Pre-test scores indicated no significant differences between the three groups. The mean
differences between pre-test and post-test scores were calculated for each group, with Group A
gaining an average of 9.55 points, Group B gaining an average of 4.2 points and Group C gaining
an average of 0.55 points. The difference scores of the 2 experimental groups differed
significantly with a greater mean gain in scores by the sensorimotor group t = 3.58 (p<0.1).

63. The type of research described is

a. descriptive
b. correlational
c. true experimental
d. quasi-experimental

64. The independent variable in the study was:

a. type of therapy
b. human figure drawings
c. the Goodenough-Harris Drawing Test
d. sensori-motor therapy

65. The hypothesis used in the study can correctly be described as:
a. a null hypothesis
b. a directional research hypothesis
c. a statistical hypothesis
d. both a) and c)

66. The dependent variable was:

a. type of training program
b. body concept development

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 c. scores on the Goodenough-Harris Drawing Test
d. sensorimotor training

67. Based in the information presented, a problem related to the internal validity of this
study is:
a. selection
b. statistical regression
c. maturation
d. none of the above

68. A therapist is preparing to introduce muscle relaxation techniques to an individual in

their home. He knows he will likely need to touch some muscle groups in order to
ensure relaxation has occurred. He has previously provided other interventions and
other interventions and there have been no misunderstandings. How should he protect
both his patient and himself from misunderstandings about the nature of the touch?

a. He should clearly explain the treatment procedure to the patient, including the need
for touch, obtain consent, ensure that another person is present if possible, and
maintain a professional manner and environment throughout.
b. He can only proceed if another person is present. If so, he should clearly explain the
treatment procedure to the patient, including the need for touch, obtain consent,
and maintain a professional manner and environment throughout.
c. He should clearly explain the treatment procedure to the patient, including the need
for touch, insist upon obtaining the signed consent of the patient, and maintain a
professional manner and environment throughout.
d. He should discuss the situation with his supervisor and record the discussion in the
patient record so that if a complaint is lodged, his intentions will have been clearly
documented.

The following vignette pertains to questions 69-73.

Mrs. Regent is a 64 year old, right-handed female with a diagnosis of cerebral vascular accident
with right hemiparesis. Four days after the CVA, the Bruunstrom stage of recovery with her
right arm was 3, and her right hand 2. She was mildly aphasic.

Mrs. Regent’s home had been the centre of her life. She enjoyed cooking, entertaining, and
bridge. One year post-stroke she had regained very little function in her upper extremity, but
was able to walk with a cane. Her Husband had re-arranged the kitchen to suit him, and he

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cooked the evening meal. She felt angry about this because she felt he had usurped her role,
but she stated that he seemed reluctant to help her resume her role.

69. The predicted course of return of motor function following a stroke progresses from:

a. ipsilateral to contralateral movement

b. proximal to distal movement
c. mass undifferentiated movement to fine, isolated movement
d. b and c

70. Soon after the stroke, instructions to this client would be most effective if provided:
a. with brief instructions and demonstrations
b. graphically or in written format
c. orally
d. with demonstrations

71. One difficulty in determining treatment effectiveness in the stroke population is the
wide range of functional deficits and the inability to single out specific variables when
analyzing the effects of treatment. A suggested research method to determine
treatment effectiveness in the heterogeneous stroke population is:

a. a case study
b. single subject research
c. large group experimental designs
d. quasi-experimental designs

72. Therapy to regain voluntary hand movement in this client should first focus on:
a. non-manipulatory activities in which movements occur in the arm and trunk
b. spasticity and muscle tone imbalance
c. prehension activities (i.e. stabilizing items with affected arm)
d. finger extension for preparation for grasp and release

73. Mrs. Regent has returned for out-patient occupational therapy one year post-stroke.
Intervention should focus on:
a. expanding her leisure AM
b. meeting with client and husband re: her role in the kitchen

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 c. the client regaining her driver’s license
d. informing her of devices such as one-handed can openers

74. Which of the following assessment methods would an OT most likely choose to learn
about a family’s values and priorities?
a. interview
b. skilled observation
c. inventory
d. standardized test

The following vignette pertains to questions 75-81.

Mr. R. is a 33 year old immigrant from India. He moved to Canada 6 months ago with his wife
and his 2 kids. He obtained employment working as an operator for Rogers Cable, but after 4
months he began to frequently call in sick for work. He had difficulty getting out of bed in the
morning and eventually gave up trying altogether. Recently, he has been experiencing
irritability, decreased sleep and depressed mood. His wife said he had trouble remembering
recent day-to-day events, making decisions and completing required tasks around the house.
He becomes frustrated easily.
When you meet Mr. R the first time, he appears withdrawn and tells you he has been aloof to
people and rarely socializes. He is in a depressed mood, lacks interest in any activity presented,
though he is spontaneous and coherent in his response to the interview. He has a history of
depression in his family. His brother was once hospitalized for a nervous breakdown and his
grandfather has a history of mental illness.
The result of ECT were good but he has evidence of short term memory loss. It was felt that
he was not ready to return to job.

75. In selecting the appropriate evaluation tool for Mr. R, the most important consideration
is

a. frame of reference to be used

b. specific area of functioning that needs to be evaluated
c. the available space and materials for evaluation
d. Mr. R's needs
e. Mr. R's coping strategy

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76. If you were working with Mr. R, using the model of human occupation as a guideline to
assess him, your major focus would be to identify:

a. Mr. R's previous hobbies and interest

b. Whether he has good self esteem
c. His typical coping strategy
d. Level of development and maturation of cognitive, psychosocial and intrapersonal
needs
e. Disruptions to Mr. R's previous normal everyday routines

77. Considering that Mr. R's diagnosis of major depression and what is known about his
problems, which of the following is most appropriate initial assessment the OT to use:

a. Comprehensive Occupational Therapy Evaluation

b. Role Checklist
c. Canadian Occupational Performance Measure
d. Occupational Case Analysis Interview Rating Scale
e. Role Change Assessment

78. The therapist should observe the following precautionary measures for depressed
patient:

a. avoid self-inflicted injuries and suicide attempts

b. monitor cardiac performance for arrhythmias
c. observe for signs of over-dose
d. observe orthostatic hypotension
e. both a and c

79. Which of the following activity can NOT be given to patient with a major depression:

a. calisthenics
b. paper mache
c. stroll in the park
d. personal hygiene and ADL
e. both a and c

80. To support the efficacy of your treatment with Mr. R, which strategy provides the most
client-centered information about the patient's gains and current functional abilities?

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 a. a review of participation in OT groups
b. a comparison of pre and post test scores of the BaFPE
c. an examination of completed goals and objectives
d. asking Mr. R's feedback
e. an exit interview such as the OPHI

81. When working with Mr. R using the life span development framework, which of the
following would give you guidelines for gathering and organizing data to describe
physical and psychosocial skills that reflect adaptive performance and mastery of life
task?

a. Role Change Assessment

b. Role Checklist
c. Life Style Performance Profile
d. Occupational Performance History Interview
e. Occupational Case Analysis Interview Rating Scale

The following vignette pertains to questions 82-91.

Justin is a 4 year old autistic child. He demonstrates an uneven scatter in developmental skills.
The most pronounced problems are delayed language acquisition, over responsiveness to both
environmental stimuli and changes in routine. He is enrolled in an integrated, low-ratio
preschool program to which OT services are provided.

82. The primary contribution of the OT to Justin’s treatment would be:

a. Employing NDT
b. Developing sensorimotor organization
c. Providing family counseling
d. Developing speech skills
e. Teaching self-care skills

83. Justin shows unusual, obsessive behaviors which interfere with his acquisition of
functional skills. The value or the OT process lies in the therapist’s ability to:
a. Enhance Justin’s sensorimotor integration
b. Provide support for Justin’s family in providing a daily stimulation program

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 c. Identify delays in language development as the key factors for skill acquisition
d. Report level of function to team members at a treatment center
e. Promote development of Justin’s interpersonal and communication skills

84. Justin presents with hyperactivity, decreased attention span and limited eye contact. An
OT sensory integration program plan would be directed towards:
a. Improving overall social-emotional functioning
b. Reducing demands made upon Justin, allowing his success experiences in his play
c. Emphasizing gross motor play
d. Decreasing arousal through inhibitory methods
e. Decreasing inappropriate behaviors through behavioral management

85. Specific characteristics which might be identified in the autistic child include:
a. Deviations in rate of development, perceptual disturbances, echolalia, and inflexible
behavior
b. Sensory processing difficulties, tonal abnormalities, unusual facial features
c. Speech and language disorders, good fine motor and perceptual skills
d. Emotional instability, increased sensibility to postural adjustment, inability to relate
to others
e. Poor bilateral coordination, simian lines, inappropriate manipulation of toys

86. The OT is planning to involve Justin in a group. Which of the following would be most
appropriate?
a. Behavior therapy
b. Milieu therapy
c. Sensorimotor therapy
d. Neurodevelopmental therapy
e. Perceptual-cognitive therapy

87. Justin was noted to seek tactile stimulation quite aggressively. He may be showing this
through:
a. Rubbing and twirling objects
b. Demonstrating peculiar hand movements
c. Forming attachments to odd objects
d. Cuddling with his peers
e. Hyperactivity in group situations

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88. Which of the following activities would provide the most tactile stimulation for Justin in
the preschool setting?
a. Water play at a standing table
b. Rolling up in a furry blanket
c. Spinning in alternate directions in a swing
d. Playing video games with peers
e. Climbing on a jungle gym

89. The pre-school staff has difficulty calming Justin following active group sessions. Using a
Sensory Integration approach, the OT should recommend:
a. Isolating Justin from the group
b. Rocking Justin in a rocking chair
c. Having Justin jump in a trampoline
d. Doing a finger painting activity
e. Having Justin do summersaults on a floor mat.

90. Justin’s father shows the OT an article on the use of music in the treatment of children
with autism. Before the therapist implements this form of treatment, the therapist should:
a. Review the current literature and professional publications on the topic
b. Tell Justin’s father that this form of treatment is not part of the service protocol
c. Read the article and gradually implement some of the principles
d. Contact the music therapist and suggest implementation of this treatment
e. Suggest to the father that he implement this treatment in the home environment
first

91. What outcome measure activity would the OT use to demonstrate the efficacy of the OT
services provided to Justin?
a. Document changes in Justin’s behavior in his home environment
b. Reassess and compare with baseline behaviours in the classroom
c. Measure his behavior at home as a result of having a new teacher
d. Implement a satisfaction survey with the staff and parents
e. Report on the treatment team on the OT intervention to date

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92. An OT is uneasy about a situation where a student OT has confided that she was
kissed and fondled by her OT supervisor. Which of the following is the best action for
the OT to take?

a) The OT must file a mandatory report.

b) The OT should not file a mandatory report.

c) The OT should consider lodging a complaint about an OT behaving unprofessionally.

d) The OT must call the College of OTs before taking any action.

93. An OT is assessing a client with physical injuries to evaluate his or her ability to return to
work. Results of the assessment lead the therapist to conclude that the client is
exaggerating symptoms in order to delay a return to work. Which of the following
statements is LEAST appropriate to include in the documentation?
a. The client exaggerated symptoms of pain and did not put full effort into the
assessment activities.
b. The client stated “I am in constant pain”
c. The client was observed to spontaneously reach above his/her head while stretching
following an assessment task.
d. The client appeared unable to reach above his/her head to activate a switch at the
job station.

94. A Using the MOHO as a frame of reference, evaluation of an individual should focus
primarily on which of the following:

 identification of problem behaviours that need to be extinguished

 clarification of thought, feelings and experiences that influence behaviour
 cognitive function, including assets and limitations
 the effect of personal traits and the environment on role performance

The following vignette pertains to questions 95-99.

Rawinder is a 21 month old girl who recently emigrated from India with her family. She is cared
for at home by her extended family. She has low toned in her face, trunk, and all four
extremities except for mildly increased tone in her long finger flexors and foot plantar flexors.
Sensation appears to be intact. There is no diagnosis at present.

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95. To screen Rawinder for developmental delays the most appropriate choice below is the:

a. Bayley Scales of Infant Development

b. Bruininks-Oseretsky Test of Motor Proficiency
c. Miller assessment of preschoolers
d. Play history

96. If none of the standardized assessments had a norm group from India, for Rawinder’s
test interpretation it is best to:
a. administer but not score the standardized assessment
b. interpret the scores related to the closest norm group
c. score the assessment documenting no match of norm group
d. use only informal assessments

97. Rawinder presents with a radial palmer grasp and extension of all digits to release when
playing with blocks. Her grasp and release presentation represents:

a. higher than expected patterns

b. age appropriate patterns
c. borderline delay
d. significant delay

98. Rawinder often has food pocketed in the lateral sulci of her mouth during meals. From a
neuro-developmental treatment (NDT) perspective, intervention would most appropriately
focus on:
a. feeding only thickened fluids to decrease the risk of aspiration
b. varying temperature and texture of food to increase stimulation
c. using gesture to imitate desired tongue movements
d. using quick stretch to oral musculature to increase tone

99. When sitting in her high chair, Rawinder’s head and trunk slump forward. To address
her position it is best to try a:
a. collar for head support and alignment
b. pelvic strap and 45 degrees to the chair back and seat
c. tilt-in-space seat tipped 20 degrees backwards
d. reclining wheelchair reclined 20 degrees backwards

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The following vignette pertains to questions 100-106.
Todd is a 4 year old child with Cerebral Palsy spastic diplegia. He was born prematurely and
weighed 2 lb at birth. Todd has been receiving occupational therapy regularly from 6 months of
age. He has a slight thumb adduction of both hands, has hand to mouth pattern in feeding but
has moderate drooling problems. During the evaluation process, he seemed to withdraw from
touch and avoid activities that challenge balance. He is stiff and awkward in movements and his
parents describe him as “clumsy”. According to his mother, Todd does not enjoy cuddling, nor
like being placed on his stomach. His preferred position is being carried with his head in the
vertical position. He calms down only when walked and bounced in this position. Todd uses
peripheral vision when engaged in activities such as writing, though opthalmological
examination revealed normal.

Todd's parents consider motor planning as the priority for Todd at this time and hope that he
would have more independence in school and other leisure activities.

100. You further find out that Todd judges space inaccurately, is afraid of walking on raised
surfaces and gets alarmed by sudden movement. An appropriate activity to give him is
a. bouncing on trampoline
b. obstacle course
c. swinging on a hammock
d. climbing a tree
e. hop-scotch

101. Which of the following therapeutic techniques is not likely to be used with Todd
a. weight bearing
b. reflex inhibitory patterns
c. vestibular stimulation
d. fast rolling
e. trunk elongation

102. To address Todd's sensory modulation problem, which of the following would you give
a. tactile sensation while he is being bounced in a vertical position
b. gradual introduction of walking on balance beam
c. preparation of mouth before feeding
d. all of the above
e. none of the above

103 Which of the following would not facilitate Todd's postural tone?
a. joint compression

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 b. sweep tapping
c. traction
d. engage patient on textured activities
e. bouncing on trampoline

104. Considering the case presented above, which of the following sensory system is a major
problem?
a. proprioceptive
b. vestibular
c. visual
d. tactile
e. auditory

105. Using the neurodevelopmental approach, which activity is best suited for managing
Todd's spasticity
a. vestibular stimulation
b. firm pressure
c. joint compression
d. fast brushing
e. spinning

106. To address Todd's use of peripheral vision, he would need remedial sessions for
a. auditory activity
b. visual perceptual activity
c. wearing glasses
d. activities involving different textures
e. sensory integration activities

The following situation pertains to questions 107-114.

Derek is ten years old and has been receiving special education services since his 3 rd Birthday,
when he was diagnosed as having autism. Derek’s current IEP includes occupational therapy
services that have been directed towards improving his fine motor skills. Derek’s mom
describes him as a child who has a good memory, can recite information, and enjoys building
and drawing. He has tactile defensiveness and difficulty with any change or transition.

107. What kind of theoretical approaches would you chose first to guide your intervention?

a. Psycho-emotional

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 b. neuro-integrative
c. social-adaptive
d. developmental
e. environmental

108. Which sensory integration assessment requires additional training and certification?
a. sensory ranking scale
b. sensory integration and praxis test
c. sensory profile
d. school function assessment
e. Kwickerlocker sensory motor history questionaire

109. What would be the best treatment option for Derek regarding his vestibular problem?
a. reading a book in the big ,overstuffed chair
b. playing on the fixed monkey bars in the schoolyard
c. playing on the swing set in the schoolyard
d. being wrapped up tight in a blanket
e. painting outdoors with chalks

110. The best activity for a 10 years old child who needs facilitation of tactile input and
kinesthetic awareness is:
a. playing a board game
b. rubbing different texture on his arms
c. playing “Simon says”
d. standing beside a wall and rolling in both directions
e. carrying heavy items

111. PDD include all of the following except:

a) Autism
b) Asperger’s syndrome
c) Rett syndrome
d) Childhood disintegrative disorder
e) Childhood bipolar affective disorder

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 112. Sensory Integration development continues throughout life but is generally
complete by what age?
a. 1 – 3 years of age
b. 4 – 5 years of age
c. 6 – 7 years of age
d. 8 – 10 years of age
e. 14-18 years of age

113. Joint compression has the following effect:

a} calming

b) organizing
c) alerting
d) all above
e) a) + b)

114. Rough-housing is an activity that provides:

a. vestibular input
b. proprioceptive input
c. tactile input
d. a) + b)
e. all above

115. An OT received a notice that a complaint was made to the college by a client. The OT
contacts the College to obtain guidance concerning the complaint process. In response
to the query, the College would:

a. Ensure that the OT understands the steps in the complaint process and suggest that
further support be sought from the provincial OT association.
b. Ensure that the OT understands the steps in the complaint process and recommend
that the OT retain an attorney.
c. Refer the OT to a knowledgeable College staff person who is completely removed
from the complaints process and who could provide assistance without creating a
conflict of interest.
d. Refer the OT to a member of the College’s complaints committee who could provide
information about the process and assistance.

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116. In a 6-month-old child, symptoms such as abnormal muscle tone, delayed or
exaggerated reflexes, postural abnormalities and delayed motor development are signs
of:

a. nothing to worry about, some 6 month old children are like that
b. autism
c. mental retardation
d. cerebral palsy

The following situation pertains to questions 117-121.

A qualitative study aims to describe the occupational performance experiences of people who
have spinal cord injuries at the level of C7 or higher, from their perspective, after discharge
from health care institutions. Approximately 16-20 male Caucasian subjects, 18-30 years of
age, in the Toronto area will be recruited. Theoretical sampling will guide subject selection/
Each subject will e interviewed once in year one, twice in years 2 and 3 of the study by one of
the two researchers. Interviews will be tape-recorded. The data will be drawn from interviews,
systematic observation, descriptions of occupational performance in the health records of the
subjects at the time of discharge from rehabilitation and at years 2 and 3 of the study. The
grounded theory approach to analysis will be used.

117. Which of the following features of this type of research BEST indicates its value for
occupational therapy:

a. the flexibility of the process

b. its focus on the details of everyday life
c. its observational techniques
d. the emphasis it places on the stories of the subjects

118. Theoretical sampling is MOST effective in determining the number of subjects recruited
for this study because:
a. sampling and data collection can end when the emerging theory is complete
b. subjects are excluded if they do not have experiences related to the developing
theory
c. the subjects in the sample can contribute to the development of the theory
d. theories direct the selection of the subject sample

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119. One assumption underlying this research is that the interview process will yield
descriptions of the subjects’ experiences of a spinal cord injury. In order for these descriptions
to BEST reflect the subjects’ perspectives, the interviewer must:
a. Assume a detached, neutral role
b. Identify closely with the subjects’ interests
c. Interact with the subject being interviewed
d. Structure the interview around the researcher’s concerns

120. Which of the following elements of formal data analysis methods will be MOST
important in describing the occupational performance experiences of people who have spinal
cord injuries:
a. comparing the data with that from other studies to strengthen the findings
b. generating categories which are coded consistently by the researchers
c. ensuring that detailed field notes are taken to complement the tape recordings
d. acting on informed hunches in analyzing and interpreting the data

121. Triangulation is a strategy which has been used in this study to enhance the credibility
of the findings. In this study triangulation is most evident in the decision to:
a. collect the data over a three year period
b. collect the data from more than one source
c. pose interview questions in a variety of ways
d. use three subject recruitment criteria.

122. An OT in private practice holds client records. The OT ceases to practice and moves to
another jurisdiction, resigning his/her registration with the College. He or she is unable
to transfer the records to another OT. What statement BEST reflects what the OT is
expected to do with the records?

a. Destroy all the records following procedures to maintain confidentiality.

b. Use registered mail to send each complete record to the last known address for the
client.
c. Use reasonable mechanisms to ensure clients can access their records and are
informed of how to do so.
d. The registrant has no specific obligations in this situation.

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123. In using an assessment that is “norm referenced”, the OT assumes that the test:
a. measures normal behaviour of children
b. compares performance with a normal standard
c. is valid and reliable
d. should be used with a normal population

124. An OT is requested to complete an assessment to determine eligibility for homemaking

services. The client arrives but states she is only participating because she was told she
had to. Which statement BEST represents the OT’s obligation?

a. Ensure that the client signs a consent form for the assessment and for release of the
report prior to proceeding, as this is high-risk situation.
b. Delay the assessment until the referral source provides a written consent from the
client for the assessment.
c. Let the client know she can refuse the assessment and who to contact to discuss the
implications.
d. Tell the client they must try their best to complete the assessment or you will have
to report their refusal to the referral source.

125. An OT administrator of a facility passes a patient’s room and overhears a nurse making
sexual remarks to a patient while providing personal care. When confronted, the nurse
excuses the remarks by stating that the “patient doesn’t understand what is said to
him”. The administrator’ s BEST course of action is to:

a. Report the incident to the nursing supervisor to ensure that the nurse is disciplined
and the behaviour does not recur.
b. Do nothing further since the patient has not understood and no damage has been
done.
c. File a mandatory report with the College of Nurses.
d. Report the incident to the nursing supervisor as the OT administrator can only file a
mandatory report about another registrant of the College of OTs of Ontario.

The following vignette pertains to questions 126-129.

Tim is a 17 year old single man who sustained a brain and spinal cord injury as a result of a
head-on car accident 6 days ago. He is in the intensive care unit, fed through a nasal-gastric
tube. He responds to stimulation inconsistently and at times in bizarre ways. He has a
supportive family and social network. His mother is the central support and has been at the
hospital 5 to 7 hours per day since his accident.

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126. Once of the occupational therapist’s intervention strategies is to enhance Tim’s level of
awareness to allow:
a. Tim to score a 2 on the Ranchos Los Amigo Level of Consciousness Scale
b. Tim to be assessed on higher level cognitive and perceptual tests
c. Tim to communicate his needs
d. His mother to see progress

127. Two weeks after the accident, Tim is sitting supported in a manual wheelchair that
allows him minimal independent mobility. At this time the goal is to:

 Increase his sitting tolerance and interaction with environment

 Begin assessment for his seating equipment needs
 Maintain the 90-90-90 rule to reduce involuntary movement
 Involve Tim in an activity while sitting

128. Swallowing remains questionable as Tim continues to be fed through a NG tube. The OT
has been asked to assess the safety of oral intake. This initial assessment would include:
a. an upper extremity functional evaluation to ensure independent feeding is possible
b. a motor and sensory evaluation of the tongue, mouth, jaw, and throat
c. determining Tim’s food preferences (by asking his mother)
d. the introduction of hot and cold liquids to his mouth

129. On his right side Tim shows moderate upper extremity spasticity and mild lower
extremity spasticity in the characteristic synergies. To address this problem you would:

a. facilitate the synergist patterns of the upper & lower extremity using Bruunstrom
principles and stages
b. expect to see dominant upper extremity flexion patterns and only minor flexion
patterns in the lower extremity
c. use exteroceptive inhibition techniques of brushing, tapping and warmth to reduce
spasticity
d. position Tim on a supportive surface with right leg flexed and right shoulder
internally rotated and abducted

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130. Six weeks after the accident Tim understands simple one-step instructions and uses
nonverbal and one-word verbal responses. To enhance Tim’s perceptual and cognitive
abilities you will:

a. incorporate appropriate perceptual challenges into his daily tasks

b. use components of the OSOT to establish a baseline of Tim’s cognitive status
c. Increase the auditory and visual stimulation in Tim’s environments
d. Alter at least 4 surface characteristics of a task to ensure a near transfer of learning

The following situation pertains to questions 131-132.

An OT in private practice has been asked to speak about joint protection at the annual meeting
of the local arthritis society. Following the presentation, the OT was approached by one of the
attendees asking for more specific advice about a personal situation.

131. Which one of the following statements BEST describes how the OT should respond?

a. tell the attendee that, under the circumstances, it would be a conflict of interest to
assist them and refer the attendee to another service provider
b. Gather sufficient information to provide the attendee with some basic
recommendations and suggest they make an appointment.
c. Tell the attendee where more information can be found, provide a business card and
tell the attendee they may call for an appointment.
d. Give the attendee a business card and tell the attendee they need a doctor’s referral
for an assessment.

132. The OT realized from this request that this situation provides an excellent opportunity
to advertise services. Which one of the following statements reflects how the OT may
MOST appropriately accomplish advertisement at this function?

a. Attach business cards to arthritis society information pamphlets and leave them at
the back of the room for attendees to pick up.
b. Leave copies of business cards at the back of the room for attendees to pick up.
c. Provide a sign-up list for attendees to leave their name and number if they would
like to be contacted and provided with more information.
d. Arrange to obtain a mailing list of the society’s members so that business cards can
be mailed.

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The following vignette pertains to questions 133-140

Mrs. F. has osteoarthritis of both hips and has been referred by her family physician to the
community OT. Information obtained by the OT on her initial home visit is as follows:

Mrs. F. is aged 70, has been widowed for one year and has no children. She lives in her own
home and has gradually lost contact with her friends. She is extremely obese and physical
problems include: severe pain upon movement in the right hip; limited range of movement in
both hips; increasing loss of balance leading to falls; chronic bronchitis; shortness of breath with
mild exertion; mild hearing loss; and visual loss secondary to severe cataracts.

Mrs. F. presents as mentally alert, talkative and eager to engage with the therapist. Due to pain
Mrs. F. spends most of the day in her chair with the television on.

133. Which of the client’s problems is most likely attributed to the normal aging process?

a. Vision loss
b. Obesity
c. Social isolation
d. Limited hip movement
e. Hearing loss

134. Assessment and documentation of Mrs. F. abilities and deficits should be in the
occupational performance areas of:
a. Vocational and avocational performance
b. Self-care, productivity and leisure
c. Activities of daily living
d. Physical, social and cultural components
e. Mental, physical, sociocultural and spiritual components

135. With regard to her visual deficit the OT should be able to improve Mrs. F’s functional
ability by:
a. Requesting a new pair of lenses for near vision
b. Requesting a new pair of lenses for distorted vision
c. Providing her with prism glasses
d. Teaching adaptive techniques to get around her house
e. Introducing stereognosis training

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136 Which of the following community services does the patient NOT require?
a. Homemaker service
b. Subsidized housing
c. Volunteer visit service
d. Bus for the handicapped
e. Handyman service (e.g. gardening)

137. The OT has recommended a transfer tub bench, grab bars, and assistance from a
homemaker. Which of the following will continue to impede Mrs. F’s independence in
tub transfers?
a. Obesity
b. Visual loss
c. Impaired balance
d. Chronic bronchitis
e. Hip pain

138. Mrs. F. wishes to improve her physical health and well-being. Which of the following
activities would be recommended initially?
a. Using a resisted stepping exercise machine
b. Joining a “aquacise” group at the local pool
c. Daily walking with the homemaker which may be graded over time
d. Joining a senior low impact exercise group
e. Using an exercise bicycle

139. The OT has completed her visit within the time the agency allows, but Mrs. F.
appears to be delaying her departure. The therapist should:
a. Arrange for a volunteer visitor to reduce Mrs. F’s loneliness
b. Inform Mrs. F. of her schedule and in a supportive manner put closure to the
visit
c. Reassure Mrs. F. that she will return another day to complete the assessment
d. Note her behavior and provide information on a senior’s support group
e. Discuss Mrs. F’s concerns and call to cancel the next client’s appointment

140. The funding agency has requested justification for continuing Mrs. F’s OT
services. Before completing the report, the OT should:
a. See if Mrs. F. wants to continue treatment

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 b. Assess her present range of motion and level of pain
c. Ask home support services for their opinion
d. Document Mrs. F’s ability to perform self-care activities
e. Complete the interest checklist with Mrs. F.

The following vignette pertains to questions 141-144.

Frank was a 68 year old man seen in the OT Dept. after a below the knee amputation. During
the initial assessment Gordon, the therapist, noted that since Frank’s retirement as the
foreman of a construction crew, he had done very little. He had no hobbies, and he belonged to
no special groups and clubs. Rather he seemed to enjoy watching television most of the day.
Recognizing the importance of human occupation, especially in people recently retired, Gordon
included the development of a hobby or a leisure interest in the treatment goals.

Over the next two months in which Gordon worked with Frank, the two men developed no
rapport at all. Whenever Gordon dealt directly with problems related to the amputation such as
discussing bathroom adaptations, Frank listened in disinterested silence, and any mention of
developing leisure skills caused Frank to become angry. Gordon tried to encourage Frank by
describing his own grandfather’s involvement in seniors’ lawn bowling and volunteer work at
the local school, but Frank quit coming to OT and never picked up the dressing aids that had
been ordered for him.

At the discharge meeting Gordon described his lack of success in Frank’s case. The head nurse
noted that Frank was troubled about OT. He had complained “Every time I went to OT that
young man was trying to get me to do some darn hobby or join some sissy group with a bunch
of old cadgers. I’be worked all my life, and now I can finally sleep in and watch TV – I deserve
it.”

141. It is clear that Gordon and Frank have differing views about work, productivity and
leisure. This could be attributed to:

a. differing cultures
b. differing ages
c. Frank’s lack of motivation
d. Gordon’s poor treatment planning

142. Gordon chose to deal directly with issues such as bathroom adaptations and dressing
aids. This is an example of which type of reasoning in action?

a. conditional reasoning

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 b. narrative reasoning
c. procedural reasoning
d. interactive reasoning

143. One might suggest that Gordon’s enthusiasm for promoting Frank’s
independence in self-care and leisure was predicated on Gordon’s goals rather than Frank’s
goals. One way to structure an assessment to ensure that the client’s goals are identified
and prioritized includes:
a. evaluation of occupational roles
b. the COPM
c. measurement of valued roles and interests
d. the Occupational History Interview

144. Gordon clearly missed part of Frank’s story, with the result that occupational therapy
intervention was not very successful. Gordon could have elicited some cues to help
clarify the uniqueness of Frank’s case if he:

a. used more valid and reliable tests of occupational performance

b. talked to the head nurse sooner than at the discharge planning meeting
c. collected data from sources other than Frank
d. listened to Frank’s “illness experience” instead of his “medical conditions”

145. The CO-OP approach is used mostly for what kind of diagnosis:

a. ADHD
b. PDD
c. Learning disabilities
d. DCD
e. ADD

146. An OT is administering a standardized test to a young client who suddenly becomes

uncooperative and complains that the test is “too hard”. The most appropriate response for the
OT would be to:
a. switch to easier items to improve the child’s self esteem
b. Terminate the session and schedule another session for the remainder of the test
c. Follow administration instructions, and note changes in behaviour

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 d. Adapt the remaining test item to ensure success

147. An OT has a longstanding therapeutic relationship with a patient in a group home in the
community. The patient asks the therapist to have coffee after work hours and
mentions a therapy issue he wishes to discuss. The therapist suspects that the patient
may in fact be asking her for a date. She is not interested in dating but wants to
preserve her rapport with the patient. The MOST appropriate response is for the
therapist to:

a. Tactfully refuse the meeting by saying, “Sorry, I’m busy tonight.” In this way the
patient will be gently dissuaded from pursuing the request.
b. Agree to the meeting. If during the meeting, the patient’s behaviour or comments
become personal, clarify professional boundaries and re-arrange the meeting during
work hours, in a professional setting.
c. Tactfully refuse the meeting. Clarify professional boundaries and rearrange the
meeting during work hours, in a professional setting.
d. Tactfully refuse the meeting by saying “Sorry, I’m already involved in a committed
relationship”. In this way, the patient will understand that a personal relationship
with the therapist will not be possible.

148. A long-term care facility has a documentation policy requiring therapists to chart clients’
OT status every 6 months. Which statement BEST describes what the therapist should
do?

a. Comply with the policy because the facility is accountable for documentation, not
the therapist.
b. Chart more frequently according to College guidelines.
c. Chart as often as you have time.
d. Comply with the policy unless changes in client condition and/or service provision
require more frequent charting.

The following vignette pertains to questions 149-

Mr. Wong is a 73 year old married man living in his own home. His wife states he is no longer
able to manage financial matters and he has become lost several times on his way home from
the store. When you assess Mr. Wong he exhibits some difficulties with word-finding and
becomes very irritable over seemingly insignificant events. He has been admitted to a
gerontology assessment unit for investigation of senile dementia of the Alzheimer’s type.

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149. The most important factor to consider when trying to differentiate between an acute
confusional state and dementia is:

a. presence of hallucinations
b. age of onset
c. level of consciousness
d. premorbid personality

150. The primary cognitive skills assessed in a mental status examination are:
a. memory, orientation, judgement
b. attention, perception, insight
c. concentration, orientation, memory
d. mood, perception, judgement

151. One of the most common changes noted by the family of someone who has Alzheimer’s
is:
a. abrupt decline in memory
b. alteration in personality
c. loss of appetite
d. pressure of speech

152. Mr. Wong’s irritability over insignificant events is most likely the result of:
a. insight into declining abilities
b. the normal aging process
c. pre-existing personality patterns
d. advancement of the disease process

153. During his first meal served in the hospital Mr. Wong became confused and agitated
when given his tray in the dining room. What would be the most appropriate initial
approach to alleviate this behaviour?

a. serve his meals to him alone in his room

b. give him positive reinforcement for good mealtime behaviour
c. supply him with a marked copy of the menu
d. present him with one food item at a time

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 154. When making recommendations about Mr. Wong’s discharge to his home or
alternative setting, the most important factor to consider is:
a. availability of community support
b. his level of function
c. family support available
d. financial resources

155. Children with a diagnosis of DCD exhibit all of the following except:

a. developmental dyspraxia
b. sensory integrative dysfunction
c. low I.Q.
d. apraxia, agnosia
e. clumsy children

156. An OT is reviewing a client’s chart before evaluating the client. Based on physician’s
history and physical examination the OT is able to identify the client’s deficits and
choose an assessment that will best assess the client’s problem areas. This form of
clinical reasoning is most likely an example:

a. procedural reasoning
b. conditional reasoning
c. interactive reasoning
d. narrative reasoning

The following vignette pertains to questions 157-160.

Diane is a 32 year old single mother and sole supporter of her two sons (aged 3 and 5 years).
She is employed as a secretary at an insurance company where she does word processing but
she is currently on time-limited sick leave. Diane has just been discharged after her third
hospitalization in seven years for major depression, and has been referred to you for out-
patient OT. She is having considerable difficulty coping with daily household tasks as well as
with her very active and demanding sons. However, she is much more pre-occupied with and
anxious about her ability to handle her paid work. She feels she must return to work as soon as
possible so that she does not lose her job. When you meet her, Diane appears withdrawn at
this point, but she tells you she has always been shy, has few friends and rarely socializes.

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157. When working with a behavioural framework which of the following assessment
instruments would be most appropriate to use with Diane?

a. Automatic Thoughts Questionnaire

b. Azima Battery
c. Comprehensive Occupational Therapy Evaluation
d. Role Checklist

158. From time to time during the intervention process, Diane becomes very involved with
her thoughts and feelings about dealing with the demands made by her sons. A
behavioural approach to intervention would indicate that you should:

a. encourage her to express these thought and emotions

b. ignore all verbalization concerning her thoughts and feelings
c. discuss the power of positive thinking and positive self talk with her
d. relate these thoughts and emotions to her own behaviour

159. If you were working with Diane using the model of human occupation as a guideline to
assessment and intervention, one major focus of your assessment would be to identify:
a. disruptions to her normal everyday routines
b. the level of development of her self-identity
c. her typical cognitive coping strategies
d. whether she has a well-established sense of self

160. Part of your intervention plan is time you spend identifying community resources
to assist Diane to deal with childcare and homemaking responsibilities. The time you spend
phoning resource centres on Diane’s behalf is documented using the Workload
Measurement system as
a. non-patient related time units
b. indirect time units
c. direct time units
d. administrative time units

161. A patient who experiences abrupt changes and swings in emotional tone despite what is
occurring in his or her external environment is best described as:

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 a. labile
b. anhedonic
c. inappropriate
d. euphoric

162. An OT is providing service in a nursing home for an elderly client who is at risk
for bedsores, but refuses to get out of bed. The client has had a recent capacity assessment
and it was determined that a guardian of the person is not needed. The OT and the client’s
family feel that he is still cognitively alert but the family wants the OT to “make him get up”.
What is the BEST course of action for the therapist to follow?
a. Discuss with the client the risk of bedsores, ways to prevent them and then do as the
client chooses.
b. The OT can only tell the family that he/she cannot make the client get up against his
wishes.
c. Initiate a reassessment of the client’s capacity, as the client is not making good
decisions.
d. Obtain assistance and get the client up into a chair.

The following vignette pertains to questions 163-167

Lise Giroux is a 60 year old divorced woman who lives with her brother in his 3-bedroom home,
with their pets (1 dog and 2 cats). Ms. Giroux was divorced 20 years ago and has no children nor
any contact with her ex-husband.
At age 55, she took early retirement from her middle-management job at BC Hydro due to
frequent interpersonal difficulties with peers and subordinates. According to the health record
from previous admissions, Ms. Giroux experienced irritability, depressed moods, and a
decreased need for sleep. As well, it is documented that she was impatient with co-workers
who couldn’t work as she did: producing a high volume of work in a short period of time,
though of questionable value at times.

Ms. Giroux has been admitted to the inpatient psychiatric unit experiencing a depressed mood,
an inability to complete required tasks around the house and trouble remembering recent day
to day events. As well, she feels frustrated when trying new things that require problem-solving
such as playing bridge. Upon initial interview Ms. Giroux appeared somewhat dishevelled and
out of sorts, the latter noted by a volitional rolling of her eyes upward at times when you asked
her questions.

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163. Considering the setting, the probable diagnosis and what is known about her problems,
which of the following is the MOST appropriate initial assessment for the OT to use with
Ms. Giroux?

a. COPM
b. COTE
c. Occupational Case Analysis Interview and Rating Scale
d. OPHI

164. Subsequent to the initial assessment, the OT learns that Ms. Giroux’ primary
pastimes are television watching, reading, and walking the dog. Ms. Giroux says that
besides seeing store clerks and people like the gardener regularly, she has little contact with
others. Which assessment would the OT choose to get a global understanding of what is
important to Ms. Giroux?
a. Interest Checklist
b. Learner Collage
c. Leisure Inventory
d. Role Checklist

165. After one week in the program, Ms. Giroux states that she is bored at home and
wants more enjoyable things to do with other people. The daily leisure skills group offers a
number of activities for patients to explore. Which of the following activities would the OT
encourage Ms. Giroux to try?
a. playing Bingo
b. debating current events
c. knitting a hat
d. learning to make pizza

166. Ms. Giroux is participating well in the program but acknowledges that her short-
temper with patients and staff makes it difficult for others to feel comfortable around her.
Therapeutic intervention for this problem could best be addressed by first:
a. asking other patient to give her behavioural feedback
b. joining a stress management group
c. clarifying the extent and context of the problem
d. keeping a list of when she gets angry at others

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167. The OT is asked to support the efficacy of his/her treatment with inpatient psychiatric
patients, including Ms. Giroux. Which strategy provides the MOST client-centered information
about the patient’s gains and current functional abilities?
a. a comparison of pre and post-test scores of the BaFPE
b. an exit interview such as the OPHI
c. a review of attendance and participation in OT groups
d. an examination of completed goals and objectives

168. An OT requests that the OTA conduct a structured interview. During this type of
interview, it is most important for the OTA to:

a. rephrase the interview questions in his or her own words

b. ask questions that he or she thinks are pertinent to this client
c. ask the questions as they are stated on the interview sheet
d. ask additional questions (other than those listed) to gain further insight into this
patient.

The following situation pertains to questions 169 & 170.

169. An OT receives a referral for a feeding assessment for a hospitalized child. While
reviewing the medical history, the OT becomes aware of multiple prior incidents of
aspiration. What is the most appropriate consent procedure for the OT to follow?

a. This is an emergency situation and no consent is required.

b. The OT should explain the assessment procedure she intends to follow and obtain
specific consent from the parents.
c. Since the parents are aware of the referral, they have already provided implied
consent. No further consent is required.
d. The OT can assume that the doctor obtained informed consent before making the
referral.

170. In the above scenario, what statement BEST represents the documentation of consent
that is advisable?
a. The general consent for treatment signed on admission is sufficient.
b. The doctor is responsible to document obtaining informed consent.
c. A written consent from the parents specifying that the OT can feed the child to
complete the assessment.
d. The OT’s documentation on the client record that consent was sought and obtained
for the assessment.

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The following scenario pertains to questions 171-176.

Mr. P is a 24 year old man with Down’s Syndrome. His IQ score places him in the moderately
intellectually disabled range. Receptive and expressive communication is limited. Mr. P
completed his special education curriculum this year followed by a 2 months work experience
placement in the janitorial area. Mr. P has been referred to a rehabilitation center for
vocational assessment.

171. As his therapist, what should your first step be in Mr. P’s assessment?

a. Administer a vocational aptitude test

b. Assess cognitive level
c. Administer an interest test
d. Develop an individual evaluation program
e. Assess his learning ability

172. What is most likely to follow the vocational assessment?

a. Job skills training
b. Social skills training
c. Job placement
d. Resume preparation
e. Job search training

173. What would be the best instructional tool for administering work samples?
a. Verbal instructions
b. Modeling and imitation
c. Independent problem solving
d. Supervised trial and error
e. Diagrammatic illustrations

174. Which assessment toll would provide the best information about Mr. P.’s vocational
potential?
a. Singer Evaluation System
b. Vocational Checklist
c. Valpar Component Work Sample Series
d. Basic Life Skills
e. Minnesota Rate of Manipulation Test

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175. During this placement at the rehabilitation center Mr. P. develops a pattern of crying
following a lunch break. The most effective technique for correcting this behavior would
be?
a. Physical contact
b. Positive reinforcement when the behavior doesn’t occur
c. Negative reinforcement during the behavior
d. Withhold reinforcement of the behavior
e. Punishment

176. During a standardized assessment, you observe the occupational therapy student
continually helping Mr. P. with the work sample. Your response would be:
a. Stop the assessment procedure and correct the student in front of Mr. P.
b. Allow the student to complete the assessment, then require the student to perform
an immediate reassessment without assistance
c. Utilize assessment results as obtained but educate the student regarding
assessment procedures
d. Stop the assessment procedure, provide Mr. P. with an alternate task and educate
the student in private
e. Stop the assessment procedure, and administer another assessment at a later time

177. A client with a psychiatric illness, living in the community has been receiving ongoing OT
services. On one visit, the OT finds the client exhibiting symptoms of psychosis and he refuses
to allow the OT into the home. During the conversation, the client states that he is not taking
his medication. Nothing in the history or situation suggests immediate safety issues for the
client or others. What is the BEST course of action for the therapist to follow?

a. Leave and discharge the client as his actions imply withdrawal of consent for
services.
b. Talk to the client to determine his capacity and try to develop a plan to continue
service.
c. Seek another individual to help you gain immediate entry.
d. Leave and contact the appropriate resources for determining capacity.

178. A client makes a written request that a therapist change the recommendations in a
report prepared by the therapist. What is the BEST course of action for the therapist to take?

a. Change the report because it belongs to the client.

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 b. Respond in writing to the request. Follow guidelines for transparency if changes are
incorporated.
c. Discuss with the client that you cannot alter records, but you will attach their
request to the report.
d. Inform the client in writing that you can never change a completed report.

The following vignette pertains to questions 178-185.

James is a 13 year old boy living in an institution. He has cerebral palsy and uses a wheelchair
for mobility. Functional skills are complicated by involuntary distal movements and dysarthria.
In activities of daily living James has attained only minimal independence.

179. James muscle tone fluctuates from low to normal with some increased tone in the
trunk. His condition would be classified as:
a. Spastic quadiplegia
b. Athetoid
c. Spastic diplegia
d. Hypertonic quadriplegia
e. Ataxic

180. Considering James symptoms, the key to working with him would be:

a. Steadying the tone and achieving midline orientation

b. Provision of opportunities to increase trunk movement
c. Use of weight shift to align pelvis
d. Stimulation through weight bearing with movement
e. Fixation with movement

181. When considering a feeding program the therapist should begin by:
a. Encouraging finger feeding
b. Implementing oral motor facilitation
c. Teaching use of adapted utensils
d. Providing supportive sitting
e. Instructing a caregiver in feeding procedures

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182. A dressing program for James should include:
a. Use of button boards
b. Provision of loose clothing
c. Written and verbal instruction
d. Positioning in prone over a wedge
e. Clothing with zippers and buttons

183. According to Erikson the major issue in James emotional development is:
a. Trust-mistrust
b. Initiative-guilt
c. Identity-role confusion
d. Autonomy-shame
e. Ego integrity-despair

184. James is frequently inappropriately touching his female therapist. Because of his age,
her response should be to:
a. Transfer James to a male therapist
b. Avoid this distractions and concentrate in activities
c. Facilitate discussion of sexuality as appropriate throughout treatment
d. Refer James to an appropriate team member for behavior counseling
e. Suggest sublimation activities as an outlet for sexual drives

185. James is frustrated about his inability to be independent socially. In order to involve him
in community activities James needs:
a. Effective communication
b. Independent self-care
c. Independent mobility
d. Social network
e. Assertiveness training

186. The OT plans to use a checklist she has designed for evaluating a child’s eating
performance skills. Which term best describes the type of evaluation the OT will be
using:

a. norm referenced
b. criteria referenced

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 c. skilled observation
d. valid and reliable

187. An OT has prescribed equipment for an elderly client and is seeking funding through the
Assistive Devices Program (ADP). The client has fluctuating cognitive status and has an
Attorney with a validated continuing power of attorney for all financial decisions but is
difficult to reach. The client wishes to sign the ADP forms himself in order to receive the
equipment more quickly. The client’s daughter visits daily and has also offered to sign
the forms. The OT realizes that, even on a “good” day, the client does not fully
understand the financial implications of the application. What is the BEST procedure for
the therapist to follow?

a. The therapist should assess the client’s capacity to consent to the funding
application.
b. The therapist should respect the client’s wishes and allow the client to sign the
forms.
c. Since the OT knows there is an Attorney, the therapist should contact him/her.
d. The therapist should have the client’s daughter sign the forms.

The following vignette pertains to questions 188-192.

Mr. and Mrs. Smythe have lived in the same urban bungalow since they were married 45 years
ago. They have a strong marriage and are good friends. They have two sons, one of whom is
married with 1 child and lives in a neighboring suburb; the other son is single an lives in a
basement suite in his parents’ home. Aothough both sons help when requested, Mr. and Mrs.
Smythe have made it very clear that they do not want to burden their sons with their problems.
“They have to live their own lives” says Mrs. Smythe.

Aged 64 years, Mr. Smythe had a stroke 6 months ago, 4 days after retiring from a part-time job
as a church custodian. Discharge from a rehab centre is expected soon. He has a dense right
hemiplegia, has no return of movement in his arm and can walk only a few steps with a quad
cane and major assistance. Fairly easy-going, he has a quiet personality and has always left
most decisions to his wife. Prior to his stroke he enjoyed walking, weekends at the family trailer
2 hours away by car, watching TV, eating out at restaurants and traveling overseas with Mrs.
Smythe for 2 weeks every year. Mrs. Smythe (aged 58 years) is an active, energetic and positive
woman who is well organized, practical, future-oriented and when necessary, strong-willed.
She does not work outside the home.

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188. The staff at the rehab centre have recommended that Mr. Smythe be placed in a long
term care facility because of his low level of recovery and need for assistance in
transfers. Mrs. Smythe wants Mr. Smythe to return home. Which of the following
criteria is ESSENTIAL for Mr. Smythe to return home without 24 hour live-in assistance?

a) Mr. Smythe can transfer and gain access to the home with assistance from his wife

b) Mr. And Mrs. Smythe have sufficient funds for home modifications
c) A community support worker is available to assist Mr. Smythe three times a week
d) A homemaker is available to assist Mr. Smythe bathe at least once a week

189. The essential criteria to return to home are met. In assessing the need for home
modifications which would enable Mr. Smythe to return home which of the following would
you do FIRST?
a. Ask Mr. and Mrs. Smythe whether they have funds for home modifications
b. Visit Mrs. Smythe in her home and discuss possible modifications with her
c. Conduct a home visit with Mr. and Mrs. Smythe prior to discharge
d. Determine the feasibility of installing a staircase elevator at the rear entrance

190. Mr. Smythe is discharged home. A male community support worker spends three days a
week at the home providing companionship and assistance to Mr. Smythe, and assisting with
home-making tasks. Mrs. Smythe does errands and visits friends at this time. When you visit 3
months post-discharge, Mrs. Smythe mentions that the support worker often does not
complete the expected home making tasks and asks for your assistance. Which is the BEST
action for you to take in this situation?
a. Call the Community Support Worker’s supervisor and explain the situation
b. Discuss ways that Ms. Smythe could share her concerns with the worker to resolve
the problem
c. Suggest that Mrs. Smythe discuss her concerns and expectations with the worker
since these may not be clear
d. Advise Mrs. Smythe to call the Community Support Worker’s supervisor and request
a change in support worker

191. Mr. and Mrs. Smythe enjoyed eating out at restaurants prior to Mr. Smythe’s stroke.
Mrs. Smythe has identified three restaurants in the neighbourhood that are wheelchair
accessible. Her husband can feed himself when meat or similar items are cut but often
spills/drops food because of the facial palsy. She is concerned that when this occurs in a
restaurant both he and other patrons will feel uncomfortable. The BEST way to address this

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concern would be to suggest that:
a. Mr. and Mrs. Smythe sit at a table at an inconspicuous location in the restaurant
b. Mr. Smythe wears a feeder (bib) so that food does not drop on his clothes
c. They go only to restaurants only with dim lighting
d. Mr. Smythe wear a lobster bib which are often worn in restaurants

192. When you visit one year after Mr. Smythe’s return home he is despondent about his
lack of improvement. He has had extra physical therapy with no effect. Some people at the
Stroke Club Mr. Smythe attends have improved after acupuncture and recommend an
acupuncturist. Mr. and Mr.s Smythe want your advice before starting these treatments. The
BEST option for you in this situation is:
a. tell them where they can obtain more information to help them make their decision
b. advise them to have the treatments but not expect any changes
c. suggest that they apply for admission to the outpatient rehab program for a physical
conditioning program
d. suggest that he have only 5 treatments at one time and assess his progress.

193. An OT assigns practice of a client’s ADL activities to an OT Assistant. The OT does not
attend the practice sessions. Each day the OT Assistant writes a progress note including
observations from the session. The therapist reviews the notes to determine when to change
the ADL program. What statement BEST describes how this should be documented?
a. The therapist must cosign every progress note.
b. The therapist should add an entry when he/she reviews the progress notes and sign
this entry.
c. No documentation is required other than the OT Assistant’s progress notes and
signature.
d. Only the OT should document the OT Assistant’s ADL sessions with the client.

194. In selecting a standardized test, an OT can assume that the test:

a. is valid
b. is reliable
c. contains normative data
d. has a standard format

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195. Of the following, the most important aspect of administrating a standardized test for an
OT is the use of:

a. subjective judgement to determine how best to administer the test

b. previous experience as a way to gauge test results
c. stated instructions for administration and scoring
d. practice to learn the best way to administer and score the test

This scenario pertains to questions 196-198.

During an OT task group you observe your client’s cognitive abilities. George is able to complete
a simple 3-step craft project with visual cueing at each step from the OT. Disregarding the
written directions, George uses the sample project as a guide. His attention span is intact for 45
minutes.

196. According to Claudia Allen, at what level is George functioning?

a. level 3
b. manual level 4
c. goal directed level 5
d. exploratory level 6, planned

197. According to Allen, besides a simple craft project, what other activity would be best for
George to work on cognitive functioning?
a. playing the game Simon says.
b. Making a sandwich
c. Budgetng for one day
d. Making a model airplane that snaps together

198. Your observation of George as described in the scenario above is representative of

which phase of the Occupational therapy process

a. screening
b. assessment
c. program planning
d. intervention

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199. A very young child is receiving service at school through a Community Care Access
Centre (CCAC). The case manager obtains written parental consent for information to be
shared between school, parents, the CCAC and the therapist. Later that year, the child
undergoes a private psychological assessment and the parents provide only the
therapist with a copy of the report. The teacher hears about the assessment from the
child and asks the therapist for a copy of the report. What statement BEST represents
the procedure the therapist should follow?

a. The therapist should talk to the parents to clarify their wishes regarding sharing the
report.
b. The therapist must obtain specific consent from the psychologist before providing
the report to the teacher.
c. The therapist can provide the report to the CCAC who can then provide it to the
teacher.
d. The consent signed by the parents for the sharing of information allows the
therapist to provide the report to the teacher.

The following vignette pertains to questions 200-205.

Chester is a 22 year old male client with Guillain-Barre syndrome. He has no speech, poor oral
functioning and all four limbs and trunk are severely involved. He has just been transferred
from an acute care hospital to the rehabilitation centre where you work. Chester has just
completed his degree in computer electronics and is engaged to be married. His fiancee visits
regularly, as do both his parents.

200. Guillain-Barre syndrome is

a. a lower motor neuron disease

b. a genetic disease
c. a disease resulting from alcohol abuse
d. a disease characterized by total recovery

201. Symptoms of Guillain-Barre syndrome include all of the following except:

a. motor weakness and paralysis
b. sensory loss
c. compromised respiratory system
d. inflammation of the spinal cord

202. The BEST approach for Chester’s first day in the rehabilitation setting would be to:
a. begin the evaluation but take frequent breaks
b. evaluate for and provide resting hand splints

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 c. set up a chin operated communication device to call the nurse
d. educate Chester about OT services

203. During Chester’s first week in the rehab centre you administer the COPM with
his fiancee as an informant, since Chester is non-verbal at the present time. To ensure that
Chester’s goals are identified, you arrange to :
a. also interview his parents in order to ascertain Chester’s history, valued pasttimes
and interests.
b. Re-administer the COPM after Chester has had some speech therapy
c. Validate the COPM results by asking Chester to write down additional problems or
cross out those that are not his priorities
d. Conduct the interview in Chester’s presence so that he can indicate acceptance or
rejection of the information offered by his fiancee.

204. Given Chester’s educational background, it might be reasonable to assume that a

good place to begin intervention is with:
a. environmental control systems
b. sitting tolerance to work at the computer
c. dressing program
d. an electric page turner for reading

205. Another priority for Chester is eating. You suggest:

a. drinking liquids through a straw
b. an electric self-feeder with pre-cut food
c. a pureed menu, scoop dish and enlarged handles on utensils
d. semi-solid foods, a mobile arm support and universal cuff

206. A child is able to copy vertical line, horizontal line and circle at age level:
a. 10 – 12 months
b. 4 to 5 years
c. 3 years
d. 5 to 6 years
e. 2 years

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207. Pinching and sealing zip-lock bag using the thumb opposing each finger, while
maintaining an open web space would be the best example of tasks used to:

a. improve children’s fine motor control and isolated finger movements

b. promote pre-writing skills in children
c. enhance right –left discrimination
d. improve children’s orientation to printed language
e. improve children’s organizational skills

208. An OT is working at a Designated Assessment Centre (DAC) providing short-term

vocational assessments. She meets a patient to whom she is attracted on a personal
level. The interest is reciprocated and the patient asks the therapist out to dinner. The
MOST appropriate course of action would be to

a. Accept a date with the patient since sexual abuse cannot be an issue when the
patient initiates the relationship.
b. Provide a phone number so the patient can contact the therapist after business
hours.
c. Inform the patient that dating is inappropriate in a patient/therapist relationship,
but that immediately following discharge, they may feel free to initiate contact.
d. Inform the patient that dating is inappropriate in a patient/therapist relationship,
but that following discharge and an appropriate lapse of time, they may feel free to
initiate contact.

208. Primary research is:

a. information gathered by the person who is doing a needs assessment

b. reviewing information that is gathered by others
c. conducting interviews
d. research results

The following vignette pertains to questions 209-213.

John is a 24 year old single male recently admitted to the inpatient psychiatric unit. He lives at
home with his parents and depends on them for financial support because he works only
sporadically, and spends his earnings very quickly. He presents as agitated, with sporadic
concentration and racing thoughts. He believes that he is a famous rock star and is shocked that
you do not recognize him. He says he cannot wait to start a project in occupational therapy.

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209. John’s symptoms MOST closely resembles which disorder?

a. obsessive compulsive disorder

b. generalized anxiety disorder
c. bipolar disorder
d. attention deficit hyperactivity disorder

210. John’s belief that he is a rock star is an example of:

a. a hallucination
b. a delusion, grandiose type
c. paranoid ideation
d. malingering

211. Which of the following would be the most appropriate goal for John?
a. improve his decision making
b. improve his independence in ADL
c. improve socialization skills
d. improve his self-control

212. Which of the following activities would be most appropriate to begin treatment?

a. a tile box
b. a 200 piece puzzle
c. a wood carving
d. a personal budget

213. John is stabilized with medications, and begins to participate in a group program
in the unit. You recognize john as representative of several young men in recent months
who have been referred to the unit, all of whom would have benefited from similar services
in the area of pre-vocational and work-related skills. You decide to approach administration
with a proposal for such a group program. A logical first step for such a proposal is:
a. a description of the goals to be achieved by the participating clients
b. a needs assessment documenting the demand for the program
c. documentation regarding the etiology of condition s such as John’s
d. the theoretical frame of reference used to guide the group intervention

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 214. A therapist is about to assess a client for driving safety in order to provide
recommendations to maximize safety. The therapist suspects that the assessment may
identify significant safety concerns that modifications or equipment are unlikely to resolve.
The client states that unless the assessment shows that he is safe to drive, he does not want
the therapist to give the results to anyone. What statement BEST represents the OT’s
obligations in this situation?
a. He/she should perform the assessment. If the assessment identifies that the client is
unsafe, the OT must report it under the Highway Traffic Act.
b. He/she should refuse to perform the assessment unless the client agrees to
disclosure of all outcomes.
c. He/she should discuss with the client the risks of unsafe driving, the OT’s duty to
warn when the client poses a risk to self or others and determine if the client still
wishes to proceed with the assessment.
d. He/she should perform the assessment in order to provide recommendations to
make the client as safe as possible. Even if the client will still pose a significant
danger to himself and others, he/she should not report the outcome without
consent.

The following vignette pertains to questions 215-217.

Shelby is a 7 year old girl who sustained second and third degree burns to her nexk, torso and
arms as a result of a scald from pulling a hot pot of soup off of the stove. She is in the second
grade, and likes colouring, crafts projects, playing soccer and watching videos. You first meet
her in the burn unit of a large general hospital.

215. To prevent contractures you provide a neck splint in the following position:

a. 10% extension (pedretti, p.620)

b. 10% flexion
c. neutral (pedretti p.620)
d. as much flexion as tolerated

216. To prevent hypertrophic scarring you Shelby with a pressure garment (a vest
with short sleeves). The appropriate time to measure Shelby and obtain the garment is:
a. as soon as possible after admission
b. the day after she has skin grafts
c. when any open areas on the skin are smaller than 2.5 cm in diameter
d. as soon as Shelby and her mother set a goal of reducing scar formation

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 217. Well into the rehab stages of intervention, you are now seeing Shelby as an
outpatient. She has returned to school but has difficulty resuming her previous activities,
mostly because her shoulder and neck range-of-motion remain limited. You select remedial
activities to improve range that:
a. require her to reach to the limits of her ROM and stretch beyond
b. challenge her muscles to the point of fatigue
c. engage her socially so that she is distracted from her physical limitations
d. contain several repetitions of the same motion within a comfortable range

218. Clinical reasoning is used to analyze important aspects of the child’s behaviour
and environment. This analysis helps to make decisions about intervention. What kind of
reasoning uses identification of specific methods to improve function:
a. interactive
b. intuitive
c. procedural
d. conditional
e. common sense

219. At age of 9 to 11 months the most advanced activity a child can do is:

a. crawl
b. creep
c. cruise
d. walk
e. run

220. An OT administrator receives a complaint from a client about services provided by an OT

under contract with the agency. There are a number of service providers involved with
the same client who the administrator feels may be able to contribute information
relevant to the complaint. What is the BEST way for her to proceed with exploring the
client’s concern?

a. The administrator should ask for the client’s permission to discuss the circumstances
surrounding the complaint with specific individuals.
b. Since the client has complained, the administrator has the authority to explore the
concerns however he or she sees fit.

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 c. The administrator can ask for and receive information from other service providers,
but should not provide any information without the client’s explicit consent.
d. The administrator should discuss the complaint only with the OT involved and no
consent is needed.

The following vignette pertains to questions 221-224.

Martha Jackson, a 40 year old wife, mother and secretary, slipped and fell on an icy sidewalk.
She sustained a fracture of the right radius and injured the median nerve. The fracture was
reduced, and a plaster cast applied to immobilize her wrist and forearm. The nerve did not
require suturing , its function is expected to return now that the fracture is set and the pressure
exerted on it from the injury has been eliminated. Martha states that she is right hand
dominant. The cast was removed this morning, and Martha has been referred to OT. She can
use her right forearm to stabilize objects, as she had been doing while the cast was on.
However, she has limited strength and dexterity given her condition and six weeks of
immobilization in the cast. Martha reports that she is on sick leave from work, and that her
current problems include difficulty with self-care and cooking. Her children, ages 6 and 8 are
able to clean up after themselves, and prepare their own breakfasts and lunches with Martha’s
supervision. He husband, a trial lawyer, has limited time available to assist Marth. As Martha’s
OT, your treatment plan focuses on two area: 1. Adapting self care and cooking activities to
Martha’s one-handed abilities; and 2. Planning a therapeutic program to promote the recovery
of her right hand function so that she can resume her self care, work and leisure tasks and
roles.

221. You begin your assessment of Martha by:

a. testing for peripheral sensation

b. scanning upper extremity ROM
c. interviewing for subjective information
d. manually testing muscles supplied by the median nerve

222. Given Martha’s current condition, probably the most appropriate method of reducing
edema to begin with is:
a. contrast baths
b. application of pressure
c. active ROM
d. elevation

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223. As Martha’s injured median nerve recovers you are able to palpate a muscle
contraction in the muscles that flex her fingers and thumb. You judge this to be grade one
muscle strength. To increase her muscle strength, an appropriate intervention is:
a. biofeedback as an adjunct to active motion
b. assisted activities with gravity eliminated
c. resisted activities with gravity eliminated
d. graded simulated work tasks

224. The median nerve is regenerating and Martha has regained some muscle
strength. You now assess her finger and thumb flexors to be grade three. In order to
continue to progress with regard to muscle strength, you must select therapeutic activities
that require Martha to use the affected muscles:
a. against resistance such as weights or springs (pedretti p.113)
b. to the point of fatigue
c. daily in all her ADL tasks
d. in PNF patterns with manual assistance

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SAMPLE CAOT EXAM QUESTION ANSWERS

* Please review answers to ensure that they are correct.

1. d
2. b
3. a
4. d
5. a
6. e
7. b
8. d
9. b
10. d
11. a
12. d
13. c
14. c
15. c
16. d
17. d
18. e
19. c
20. d
21. c
22. d
23. b
24. b
25. b
26. d
27. e
28. d
29. c
30. e
31. d
32. d
33. d
34. a ? or c
35. b
36. c
37. d
38. b
39. b
40. a
41. a

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42. e
43. e
44. b
45. c
46. a
47. a
48. d
49. c
50. a
51. c
52. b
53. d
54. b
55. c
56. d
57. d
58. c
59. a
60. a
61. a
62. a
63. c
64. b
65. a
66. a
67. c
68. a
69. d
70. a
71. d
72. a
73. ? b or d
74. a
75. ? b or e
76. a
77. ? a or d
78. e
79. a
80. d
81. d
82. b
83. b
84. d
85. ?
86. c
87. a

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88. b
89. b
90. a
91. b
92. c
93. a
94. d
95. a
96. c
97. d
98. d
99. d
100. c
101. d
102. a
103. a
104. b
105. c
106. b
107. d
108. b
109. c
110. e
111. e
112. c
113. d
114. e
115. a
116. d
117. d
118. d
119. c
120. a
121. b
122. c
123. b
124. c
125. c
126. c
127. a
128. b
129. a
130. a
131. c
132. b
133. e

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134. b
135. d
136. b
137. e
138. c
139. b
140. a
141. d
142. c
143. b
144. d
145. d
146. b
147. c
148. d
149. b
150. d
151. b
152. a
153. d
154. b
155. c
156. a
157. c
158. d
159. a
160. c
161. a
162. a
163. c
164. a
165. a
166. d
167. d
168. c
169. b
170. c
171. c
172. a
173. b
174. b
175. d
176. d
177. b
178. b
179. b

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180. a
181. d
182. b
183. c
184. c
185. d
186. c
187. c
188. a
189. c
190. b
191. d
192. a
193. b
194. d
195. c
196. a
197. d
198. b
199. a
200. a
201. d
202. c
203. d
204. b
205. d
206. c
207. a
208. d
209. c
210. c
211. b
212. d
213. d
214. b
215. c
216. c
217. d
218. a
219. c
220. c
221. c
222. c
223. c
224. b

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REFERENCES

CAOT website and the provincial associations. Ontario, British Columbia and Alberta all have
significant information on their websites for those new to the profession.

Canadian Association of Occupational Therapists. (2000). Certification Examination for

Occupational Therapists: Application/procedures and examination format. Ottawa, ON: CAOT
Publication.

Sladyk, Karen. (1998). OTR Exam Review Manual, 2nd edition. Thorofare, NJ: Slack Incorporated.

Canadian Association of Occupational Therapists: Website, Certification Exam

http://www.caot.ca/

Canadian Association of Occupational Therapists: Resource Manual

http://www.caot.ca/pdfs/ResMan05.pdf

McMaster University: Centre for Student Development, Booklets

http://csd.mcmaster.ca/booklets/14.html

University of Northern British Columbia: Learning Skills Centre – Strategies for Multiple Choice
http://quarles.unbc.ca/lsc/jtmulcho.html

University of Western Ontario: SDC’s Learning Skills Service - Writing a Successful Multiple
Choice Exam http://www.sdc.uwo.ca/learning/mcwrit.html

OT Study Guides

Johnson, C., Lorch, A., & DeAngelis, T. (2001). The Occupational Therapy Examination Review
Guide, 2nd edition. Philadelphia, PA: F.A. Davis Company.

Sladyk, Karen. (1998). OTR Exam Review Manual, 2nd edition. Thorofare, NJ: Slack Incorporated.

Sladyk, Karen. (1998). OT Study Cards in a Box. Thorofare, NJ: Slack Incorporated.

OT Resources

Canadian Association of Occupational Therapists. (Revised 2002). Enabling occupation: An

occupational therapy perspective. Ottawa, ON: CAOT Publication ACE.

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Canadian Association of Occupational Therapists. (1991). Occupational therapy guidelines for
client-centred practice. Toronto, ON: CAOT Publications ACE.

Canadian Association of Occupational Therapists. (1993). Occupational therapy guidelines for

client-centred mental health practice. Toronto, ON: CAOT Publications ACE.

Law, M., Baptiste, S., Carswell, A., McColl, M.A., Polatajko, H., & Pollock, N. (1994). Canadian
occupational performance measure. (2nd ed.). Toronto, ON: CAOT Publications ACE.

Study Skills Resources

Deese, J., & Deese, E. K. (1994). How to study. New York: McGraw-Hill.

Ellis, D. B. (1997). Becoming a master student: Canadian second edition. Rapid City, SD: College
Survival, Houghton Mifflin.

Fleet, J., Goodchild, F., & Zajchowski, R. 3rd Ed. (1999). Learning for success: Effective strategies
for students. Harcourt Brace & Company, Canada.

Kiewra, K. A., & Dubois, N. F. (1998). Learning to learn: Making the transition from student to
life-long learner. Needham Heights, MA: Allyn & Bacon.

Lengefeld, U. (1994). Study skills strategies: Your guide to critical thinking. CA: Crisp
Publications, Inc.

Richardson, F. (1990). Coping with exam anxiety. Athabasca: Athabasca University.

Siebert, A., & Gilpin, B. (1997). The adult student's guide to survival and success. Oregon:
Practical Psychology Press.

Internet Resources:

Canadian Association of Occupational Therapists http://www.caot.ca

College of Occupational Therapists of Ontario http://www.coto.org

McMaster University: Centre for Student Development

http://csd.mcmaster.ca/booklets/14.html

National Board for Certification in Occupational Therapy (American)

http://www.nbcot.org/index.htm

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For free copies of this manual contact [email protected]. Do not change content in anyway that may falsify
the information or take away from the information collected by the author. Share freely.

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