Obstacles to O.T. Process & O.T. areas of practice in Neurological conditions T.B.I : Falls

  Introduction:

Traumatic brain injury (TBI) is a nondegenerative, noncongenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness.The definition of TBI has not been consistent and tends to vary according to specialties and circumstances. Often, the term brain injury is used synonymously with head injury, which may not be associated with neurologic deficits. The definition also has been problematic with variations in inclusion criteria. [1] 

The leading causes of TBI are as follows [2]   :

• Falls (28%) 

• Motor vehicle crashes (20%) 

• Being struck by or against objects (19%) 

• Assaults (11%)

Mortality rates after brain injury are highest in people with a severe TBI. In the first year after a TBI, people who survive are more likely to die from seizures, septicemia, pneumonia, digestive conditions, and all external causes of injury than are other people of similar age, sex, and race.[3] However, the mortality rate after severe TBI has decreased since the late 20th century.[4]                                              

Some particular segments of the populace are at increased risk of sustaining a TBI, including the following:

• Young people [5]

• Low-income individuals 

• Unmarried individuals 

• Members of ethnic minority groups 

• Residents of inner cities 

• Men [5] 

• Individuals with a history of substance abuse 

• Individuals who have suffered a previous TBI

Classification as Primary or Secondary injury 

TBI may be divided into primary injury, which occurs at the moment of trauma and secondary injury, which occurs immediately after trauma and produces effects that may continue for a long time. Primary injury is induced by mechanical force and occurs at the moment of injury. Secondary injury is not mechanically induced. It may be delayed from the moment of impact, and it may superimpose injury on a brain already affected by a mechanical injury.[5] 

Classification as Focal or Diffuse Injury

Another injury classification based on clinical and neuroradiologic evaluation has been proposed. In this classification, TBI would be described as focal or diffuse. Focal injuries include scalp injury, skull fracture, and surface contusions and are generally be caused by contact. Diffuse injuries include DAI, hypoxic-ischemic damage, meningitis, and vascular injury and are usually caused by acceleration-deceleration forces. These 2 forms of injury are commonly found together.

Medical Complications [1]: 

• Posttraumatic seizures: Posttraumatic seizures (PTS) frequently occur after moderate or severe TBI. Seizures are usually general or partial, and absence seizures are uncommon. Seizures are classified according to the time elapsed after the initial injury: Immediate seizures occur in the first 24 hours. Early seizures occur in the first 2-7 days, and late seizures occur after 7 days.

• Hydrocephalus

• Deep vein thrombosis

• Heterotopic ossification

• Spasticity

• GI and GU complications

Symptoms of TBI [1]:

• Insomnia

• Cognitive decline

• Posttraumatic headache

• Posttraumatic depression

O.T. Process & Areas of Practice:

• This process includes several stages, which for the experienced therapist may not be linear in nature. The stages are:

1. Referral

2. Information gathering

3. Initial assessment

4. Needs identification/ problem formation

5. Goal setting

6. Action planning

7. Action

8. Ongoing assessment & revision of  action

9. Outcome & outcome measurement

10. End of intervention

11. Review

• while the  Areas of Practice are :

1. Assistance and training in performing daily activities, depending on the needs.

2. Physical exercises, to increase good posture and joint motion as well as overall strength and flexibility.

3. Instruction in protecting the joints and conserving patient's energy.

4. Evaluation of the daily living needs and assessment of patient's home and work environments, with recommendations for changes in those environments that will help patients to continue their activities.

5. Assessment and training in the use of assistive devices, such as special key-holders for people with stiff hands, computer-aided adaptive equipment, and wheelchairs.

6. Fitting splints or braces.

7. Guidance for family members and caregivers. 

Obstacles to O.T. Process: 

1. Referral : 

a. O.T. role is not clear to the other medical team members or the most of the patients who need O.T. intervention

b. There is no syndicate of O.T. in Egypt to put job description for O.T. and prevent interference between the role of O.T. and the other medical team members  

c. O.T. Profession is a new born field in Egypt

d. O.T. in Egypt – therapists and service places/clinics/centers - needs to be promoted

e. The connection between O.T.  and the other medical team members needs to develop

2. Information gathering

a. There is no connection between O.T. and the other medical team member to discuss pt.'s case

b. The pt.'s health promotion level is very low, so pt. is not a good source to gather information unless if he/she has some objective data through investigations he/she had done –lab. /imaging.

c. Bad/no documentation system to help in gathering data

3. Initial assessment

a. It is necessary to the other medical staff members to know the role of O.T.  especially in acute phase of the insult to allow O.T. to assess the pt. from the first stages in I.C.U. , so O.T. can apply his tests 

4. Needs identification/ problem formation

a. There is no proper assessment place to assess all the functions of the pt. 

5. Goal setting

a. Due to pt.'s low level health promotion and education , the pt.'s goal and the O.T.'s goal  sometimes doesn't match  

6. Action planning 

a. Due to the low level of health promotion in Egypt, it is very hard to share almost of pt./pt.'s family in treatment plan  

7. Action

a. Due to the low level of health promotion in Egypt, it is hard to engage pt. in home program , and make sure that the pt. will be committed 

b. Due to financial causes , insufficient income  and bad insurance system, it is hard to make home adaptation to ease putting pt. independent and functioning 

c.It is hard to engage pt. in social activities matching his/her abilities
d.It is hard for the pt. to has a job matching his/her abilities
8. Ongoing assessment & revision of  action

a. There is no a proper assessment place to assess all the functions of the pt. objectively , as taking a feedback from the pt. is not fair due to different point of views 

b. Bad documentation system to allow the O.T. to compare between each assessment.

9. Outcome & outcome measurement

a. Bad documentation system to allow the O.T. to compare between the pt.'s function before and after the O.T. intervention, and calculate the duration of the whole O.T. treatment and compare it with the expected time of O.T. program for this pt.'s case.

b. There is no a proper assessment place to assess all the functions of the pt. 

c. It is hard to engage pt. in a long term treatment program due to financial causes

10. End of intervention

a.The treatment may be ended before the right time , due financial reasons

11. Review

a. Bad documentation system to allow the O.T. to review the results , and process them 

Obstacles of OT Areas of Practice:

1. Assistance and training in performing daily activities

a. There is no places to train pt. on all functions needed 
b. Training a pt. needs a long time session while the number of O.T. is  so little and number of pt is great 

2. Physical exercises, to increase good posture and joint motion as well as overall strength and flexibility.

a. No obvious obstacles in this area as no obstacles in physical exercises for Physical therapists 

3. Instruction in protecting the joints and conserving patient's energy.

a. Lake of educational tools as using multimedia, brochures, to remind pt. about the instructions
 b.Due to financial causes pt. can't be committed to the instructions as he/she has to work hard for his/her life or family    

4. Evaluation of the daily living needs and assessment of patient's home and work environments, with recommendations for changes in those environments that will help patients to continue their activities.

a. No place to assess pt.'s ADLs 

b. There is no enough O.T.  tools supplies with good qualities

c. Changing home environment ,is very hard due to high costs  

d. Evaluating and changing work environment almost not available, as the role of O.T. is not totally understood in Egypt, needed to be defined through founding an O.T.  syndicate

5. Assessment and training in the use of assistive devices, such as special key-holders for people with stiff hands, computer-aided adaptive equipment, and wheelchairs.

a. There is no enough assistive devices supply in Egypt ,not all designs are available , so you almost need to design it and make it

b. The available assistive devices are expensive with no so high quality  

6. Fitting splints or braces.

a. Expensive splints and braces 

b. Not all needed splints and braces are available depending on its complexity 

c. Their quality are not so high , it cause further complications as pressure sores 

7. Guidance for family members and caregivers.

a. Educational materials are not available to help family members and caregivers

b. There no educational hot lines to offer guidance service  

PEOP Model applied to people with TBI:

              * Person :

• Paralysis / paresis  depending on the severity and location of the brain injury

• Spasticity

• Posttraumatic agitation

• Cognitive decline

• Posttraumatic depression

• GI and GU complications

   *           Environment

• Psychosocial –home , school &  work

• Physical

• Sensory

• Cultural

• Institutional

           *     Occupation:

• Self-care

• School/ work

• Leisure

References:

1. Segun T. Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed), Former Clinical Instructor, Mount Sinai Medical School; Current Director, Pain and Injuries Rehabilitation Services, PMRehab Pain and Sports Medicine Associates.Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology . www.emedicine.com

2. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, Ga: Centers for Disease Control and Prevention; Jan 2006.

3. Harrison-Felix C, Whiteneck G, Devivo MJ, et al. Causes of death following 1 year postinjury among individuals with traumatic brain injury. J Head Trauma Rehabil. Jan-Feb 2006;21(1):22-33.

4. Lu J, Marmarou A, Choi S, et al. Mortality from traumatic brain injury. Acta Neurochir Suppl. 2005;95:281-5.

5. Silver JM, McAllister TW, Yodofsky SC, eds. Textbook of Traumatic Brain Injury. Arlington, VA:. Arlington, Va: American Psychiatric Publishing; 2005:27-39.

6. Allan H. Ropper , Robert H. Brown , Adams and victor's princeples of Neorology , 2005 8th Edition

7. Albert B. Lowenfels, MD, Professor of Surgery, New York Medical College, Valhalla, New York , Famous Patients, Famous Operations 2003 

 www.medscape.com

EXTRA ASSIGNMENT - Language Assignment

* Unkempt:

means literally uncombed. It was coined from the prefix un-

'not' and the past participle of the now defunct

verb kemb 'comb'. This came from a prehistoric

Germanic *kambjan, a derivative of *kambaz

'comb' (ancestor of the English noun comb). It

began to be replaced by the new verb comb in the

14th century

 *Accuse:

comes via Old French

acuser from the Latin verb acc.s.re, which was

based on the noun causa 'cause'. but cause in

the sense not of 'something that produces a

result', but of 'legal action' (a meaning

preserved in English cause list, for instance).

Hence acc.s.re was to 'call someone to account

for their actions'.

The grammatical term accusative 

(denoting the case of the object of a verb in Latin

and other languages) is derived ultimately from

acc.s.re, but it arose originally owing to a

mistranslation. The Greek term for this case was

ptosis initiates 'case denoting causation' . a

reasonable description of the function of the

accusative. Unfortunately the Greek verb

aitiasthai also meant 'accuse', and it was this

sense that Latin grammarians chose to render

when adopting the term.

* Ache:
[OE] Of the noun ache and the verb ache,

the verb came first. In Old English it was acan.

From it was formed the noun, æce or ece. For

many centuries, the distinction between the two

was preserved in their pronunciation: in the verb,

the ch was pronounced as it is now, with a /k/

sound, but the noun was pronounced similarly to

the letter H, with a /ch/ sound. It was not until the

early 19th century that the noun came regularly

to be pronounced the same way as the verb. It is

not clear what the ultimate origins of ache are,

but related forms do exist in other Germanic

languages (Low German āken, for instance, and

Middle Dutch akel), and it has been conjectured

that there may be some connection with the Old

High German exclamation (of pain) ah.

*Acre:

[OE] Acre is a word of ancient ancestry,

going back probably to the Indo-European base

*ag-, source of words such as agent and act. This

base had a range of meanings covering ‘do’ and

‘drive’, and it is possible that the notion of

driving contributed to the concept of driving

animals on to land for pasture. However that may

be, it gave rise to a group of words in Indo-

European languages, including Latin ager

(whence English agriculture), Greek agros,

Sanskrit ájras, and a hypothetical Germanic

*akraz. By this time, people’s agricultural

activities had moved on from herding animals in

open country to tilling the soil in enclosed areas,

and all of this group of words meant specifically

‘field’. From the Germanic form developed Old

English æcer, which as early as 1000 AD had

come to be used for referring to a particular

measured area of agricultural land (as much as a

pair of oxen could plough in one day).

*Adam’s apple :

The original apple in question was the forbidden fruit of the tree of the

knowledge of good and evil, which the serpent in

the Garden of Eden tricked Eve into eating, and

which she in turn persuaded Adam to eat. It was

traditionally believed that a piece of it stuck in

Adam’s throat, and so it became an appropriate

and convenient metaphor for the thyroid

cartilage of the larynx, which protrudes

noticeably in men.

*Ado :

In origin, ado (like affair) means

literally ‘to do’. This use of the preposition at

(ado = at do) is a direct borrowing from Old

Norse, where it was used before the infinitive of

verbs, where English would use to. Ado persisted

in this literal sense in northern English dialects,

where Old Norse influence was strong, well into

the 19th century, but by the late 16th century it

was already a noun with the connotations of

‘activity’ or ‘fuss’ which have preserved it

(alongside the indigenous to-do) in modern

English.

*Advocate :

 Etymologically, advocate

contains the notion of ‘calling’, specifically of

calling someone in for advice or as a witness.

This was the meaning of the Latin verb advocāre

(formed from vocāre ‘call’, from which English

also gets vocation). Its past participle,

advocātus, came to be used as a noun, originally

meaning ‘legal witness or adviser’, and later

‘attorney’. In Old French this became avocat, the

form in which English borrowed it; it was later

relatinized to advocate. The verb advocate does

not appear until the 17th century.

The word was also borrowed into Dutch, as

advocaat, and the compound advocaatenborrel,

literally ‘lawyer’s drink’, has, by shortening,

given English the name for a sweetish yellow

concoction of eggs and brandy.

*Calf:

 English has two distinct words calf, both of

Germanic origin. Calf ‘young cow’ goes back to

Old English cealf, descendant of a prehistoric

West Germanic *kalbam, which also produced

German kalb and Dutch kalf. Calf of the leg 

was borrowed from Old Norse kálfi, of unknown

origin.

*Camera:

 Latin camera originally meant

‘vaulted room’ (a sense preserved in the

Radcliffe Camera, an 18th-century building

housing part of Oxford University library, which

has a vaulted roof). It came from Greek kamárā

‘vault, arch’, which is ultimately related to

English chimney. In due course the meaning

‘vaulted room’ became weakened to simply

‘room’, which reached English, via Old French

chambre, as chamber, and is preserved in the

legal Latin phrase in camera ‘privately, in

judge’s chambers’.

In the 17th century, an optical instrument was

invented consisting of a small closed box with a

lens fixed in one side which produced an image

of external objects on the inside of the box. The

same effect could be got in a small darkened

room, and so the device was called a camera

obscura ‘dark chamber’. When the new science

of photography developed in the 19th century,

using the basic principle of the camera obscura,

camera was applied to the picture-forming box

* Cancer :

comes from Latin cancer,

which meant literally ‘crab’. It was a translation

of Greek karkínos ‘crab’, which, together with

its derivative karkínōma (source of English

carcinoma ) was, according to the ancient

Greek physician Galen, applied to tumours on

account of the crablike pattern formed by the

distended blood vessels around the affected part.

Until the 17th century, the term generally used

for the condition in English was canker, which

arose from an earlier borrowing of Latin cancer

in Old English times; before then, cancer had

been used exclusively in the astrological sense.

The French derivative of Latin cancer, chancre,

was borrowed into English in the 16th century

for ‘syphilitic ulcer’.

*Candid :

 Originally, candid meant simply

‘white’; its current sense ‘frank’ developed

metaphorically via ‘pure’ and ‘unbiased’.

English acquired the word, probably through

French candide, from Latin candidum, a

derivative of the verb candēre ‘be white, glow’

(which is related to English candle,

incandescent, and incense). The derived noun

candour is 18th-century in English. Candida, the

fungus which causes the disease thrush, got its

name from being ‘white’. And in ancient Rome,

people who were standing for election wore

white togas; they were thus called candidāti,

whence English candidate

*Ellipse :

 Greek élleipsis meant literally

‘defect, failure’. It was a derivative of elleípein,

literally ‘leave in’, hence ‘leave behind, leave

out, fall short, fail’, a compound verb formed

from the prefix en- ‘in’ and leípein ‘leave’

(which is related to English loan and relinquish).

It was borrowed into English in the 17th century

as ellipsis in the grammatical sense ‘omission of

a word or words’, but its mathematical use for an

‘oval’ (enshrined in the form ellipse, borrowed

via French ellipse and Latin ellīpsis) comes from

the notion that a square drawn on lines passing

vertically and laterally through the centre of an

ellipse ‘falls short’ of the entire length of the

lateral line.

*Else:

 [OE] Else shares its sense of ‘otherness’

with related words in other parts of the Indo-

European language family. It comes ultimately

from the base *al-, which also produced Latin

alter ‘other’ (source of English alter) and alius

‘other’ (source of English alibi and alien) and

Greek állos ‘other’ (source of the prefix allo- in

such English words as allopathy, allophone, and

allotropy). Its Germanic descendant was *aljo-

‘other’, whose genitive neuter case *aljaz, used

adverbially, eventually became English else.

*Insult: 

 The -sult of insult comes from a word

that meant ‘jump’. Its source was Latin insultāre

‘jump on’, a compound verb based on saltāre

‘jump’. This was a derivative of salīre ‘jump’,

source in one way or another of English assail,

assault, desultory, salacious, and salient. Old

French took insultāre over as insulter and used it

for ‘triumph over in an arrogant way’. This was

how the word was originally used in English, but

at the beginning of the 17th century the now

familiar sense ‘abuse’ (which had actually

developed first in the Latin verb) was

introduced.

 *Insulin:

 a hormone which promotes

the utilization of blood sugar, was first isolated

in 1921 by F G Banting and C H Best. Its name,

which was inspired by the fact that insulin is

secreted by groups of cells known as the islets of

Langerhans (insula is Latin for ‘island’), was

actually coined in French around 1909, and was

independently proposed in English on a couple

of further occasions before the substance itself

was anything more than a hypothesis.

*Jaw :

 Given that it is a fairly important part of

the body, our knowledge of the origins of the

word for ‘jaw’ is surprisingly sketchy. The Old

English terms for ‘jaw’ were céace (modern

English cheek) and ceafl (ancestor of modern

English jowl), and when jaw first turns up

towards the end of the 14th century it is in the

form iowe. This strongly suggests a derivation

from Old French joe ‘cheek’, but the connection

has never been established for certain, and many

etymologists consider it more likely that it is

related to chew.

*knee:

 [OE] The majority of modern European

words for ‘knee’ go back to a common Indo-

European ancestor which probably originally

signified ‘bend’. This was *g(e)neu or *goneu,

which lies behind Latin genu ‘knee’ (source of

French genou and Italian ginocchio, and also of

English genuine) and may well be connected

with Greek gōníā ‘angle’, from which English

gets diagonal. It passed into Germanic as

*knewam, which over the centuries has

diversified into German and Dutch knie,

Swedish knä, Danish knoe, and English knee. The

derivative kneel [OE] was formed before the

Anglo-Saxons reached Britain, and is shared by

Dutch (knielen).

*Limb:

 [OE] The Old English word for ‘limb’ was

lim. Like thumb, it later (in the 16th century)

acquired an intrusive b, which has long since

ceased to be pronounced. It has cognates in

Swedish and Danish lem, and Dutch lid ‘limb’ is

probably related too.

_______________________________________________________________________________

Reference :

John Ayto, Word Origins 2e_ dictionary of English etymology 2005

What is O.T

Occupational Therapy is "The therapeutic use of work, self-care, and play activities to increase development and prevent disability. It may include adaptation of task or environment to achieve maximum independence and to enhance the quality of life." 

AOTA,1976

One's occupation can therefore be defined as the way in which we occupy our time. Thus, our time is divided into three categories of activities in which we take part daily: 

Self-Care: sleeping, eating, grooming, dressing, and toileting 

Work: effort that is exerted to do or make something, or perform a task 

Leisure: free, unoccupied time in which one chooses to do something they enjoy