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105 Cards in this Set
- Front
- Back
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MOHO
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Model of Human Occupation
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About MOHO
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= Grand theory/Conceptual model
* NOT a treatment Model b/c it doesn't have any specific interventions - Kielhofner came up with this distinction |
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MOHO founder
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- Created by Gary Kielhofner in the 80's
- Continuous research at the university of illinois chicago and CREATED the model for their doctoral program - Kielhofner died of cancer last year |
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MOHO among practitioners
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** Most commonly used in practice (according to the NBCOT study)
- is the only CONCEPTUAL MODEL of the grand teories "Top CM to treat humans" |
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Lifespan Issues of MOHO
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- MOHO has beed designed to apply across the lifespan.
AND, it actually has research to support this claim |
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Research supporting MOHO
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Chronic pain
Children with ADHD TBI Dementia AIDS Adolescents with mental illness Homeless children and adults Battle-fatigued soldiers Victims of war Victims of social injustice |
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Review
Frame of Reference vs. Grand Theory vs. Practice/treatment models |
A FOR is a way to look at a problem.
A grand theory/conceptual model is how to approach that specific diagnosis Practice/treatment modles are the actual treatment used (i.e. the sensory profile) |
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Places where MOHO has been used
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hospitals
outpatient clinics residential facilities nursing homes rehabilitation programs work programs prisons and correctional settings community based organizations |
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Person Concepts (of MOHO)
Volition 1) Personal Causation 2) Values 3) Interests |
Volition = internal/inherent concepts. Is why we chose the occupations we chose.
- Idea that we are motivated to choose things that are important to us. 1) Personal Causation = thoughts & feelings of your effectiveness in engaging in these occupations NOTE so if you think you can't do something, you limit yourself 2) Values = beliefs/understanding of whats good and right. Values tell us what matters to us. 3) Interests = are driven by the satisfaction of completing an occupation Volition impacts why we do everything & effects how you make choices. |
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Person Concepts (of MOHO)
Habituation 1) Habits 2) Roles |
Habituation = how people organize patterns and routines
Habits: automatic Roles: give sense of Obligation that go with their identities |
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Person Concepts
Performance Capacity |
= life roles have their own set of obligations
- Are the underlying mental and physical abilities we have = actually being able to do it. |
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Environmental Concerns
(External) |
= Physical and Social Environment
MOHO sees the process of doing an occupation as both internal (volition) and External Concerns - Social Environment = subtext of what you're doing in these areas 1. Political 2. Economic |
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Dimension of "Doing"
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1. Occupational Participation
= work, play or ADLs that are part of roles in context & necessary for well being and performance 2. Occupational Performance = Doing any major activity or life task 3. Occupational Skill = The actions that make up occupational performance |
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OA and MOHO
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OA is defined as the interaction between person, environment and internal adaptive processes that occur when individuals engage in their occupations as a person.
NOtes: = a process of creating and enacting a positive occupational Identity - is the ability to interact in the environment Kielhofner Book definition = Identity & Environment |
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MOHO assessments
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"MOHOST" is a key evaluation to assess goals.
Examples: Observation, Client self Report (pg. 158) |
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Steps for Using MOHO in Practice
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1) Generate Questions: in order to begin a therapeutic relationship, an INTERVIEW must bring forward the life circumstances, roles and needs of the client (i.e. ask what their wants and needs are
2) Gather Information = answer the questions you generated in the first step ex: In the interview you find out their job is important, so ask what do you need to do to fulfill that job 3) Creating a theory based on Understanding of the Client - The therapist creates a THEORY-BASED understanding of the client - Identify problems - Identify strengths - Environment * This step is more introspective; i.e. steps 1 and 2 involve the client. = creating a mental understanding of the client 4) Generating Goals and Strategies= 1. ID what will CHANGE from Therapy participation (where you generate goals and strategies) 2. How will you create the change/what strategies will you use to make that happen |
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Using MOHO in Practice: Implementing and Monitoring Therapy
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= using many different tools to bring about change.
- Keep the client in the center of what's happening. Includes: Validation: "coaching feedback" Identifying Giving Feedback Advising Negotiating Structuring Coaching Encouraging Physical Support |
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Using MOHO in Practice:
Collecting information to assess outcomes |
- address which goals have been achieved
- Use of structured assessments = PERFORMANCE ASSESMENTs i.e. what you did this area well; etc. - Participate in evidence gathering ** Provide timely assesment & goal attainment |
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The Biomechanical Frame of Reference
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FRAME OF REFERENCE
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History of Biomechanical
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- developer unknown
- Baldwin = first to analyze joint and muscle function during purposeful activity - Dr. Licht: Added the concept of work tolerance (endurance training) |
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Biomechanics
Static Dynamic |
= the application of mechanics to the human body
Static = concerned with the body at rest/innate ability Dynamic = concerned with the body at motion/what you can do |
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OT and biomechanics
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OT's try to deal with static mechanical principals.
- OT's don't have dynamic measurements (ie force plates on the floor to determine foot pressure); PT's have some, but use the naked eye |
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Theoretical Foundations of the Biomechanical FOR
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- Anatomy
- Physiology - Kinesiology * Newtonian Physics * Kinesmatics |
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Kinetics
Kinematics |
Kinetics = The study of how forces produce motion
Kinematics = the study of motion of body parts in time (direction, speed, etc). |
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Purpose of Bioimechanics
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- To understand how the body is designed for and used to accomplish movement
1. Prevent deformity and maintain existing capacity for motion ex: wheel chair positioning, splinting 2. Remediate weak components of performance to enable occupational function ex: ROM, endurance 3. Compensate for lost components of performance to enable occupational function ex: adaptive devices |
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(3 of 6) Assumptions of Biomechanical FOR
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1. Successful motor activity is based on physical mobility and strength
- Must have basic strength 2. Repeated graded movement maintains and improves function - Exervise can impact 3. The body must be rested, then stressed - There is a cycle in which to do this |
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(4-6) Assumptions cont.
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4. Purposeful activities, exercise, and physical agent modalities can be used to remediate movement deficits
5. The person will automatically regain function after strength, ROM, and endurance are gained 6. CNS (brain and spinal cord) must be intact for Biomechanics to work |
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Major Concepts of Biomechanical FOR
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1. Range of Motion
2. Muscle Strength 3. Endurance 4. Structural Stability 5. Edema Control ** Note if it deals w/ any of these 5 it is w/in the biomechanical model - Can be used with any other theory/FOR (i.e. this + something else to treat stroke patients) *** THIS CANNOT BE USED BY ITSELF w/CNS traumas |
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5 major concepts:
1) Range of Motion |
= The extent to which body parts are able to move through an arc.
- Direction and extent of movement dependent on bony structures, muscles and tissues holding joint together - Active and Passive ROM - ROM is limited by damage, edema, pain, tightness and swelling Active ROM Passive ROM |
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ROM assessment
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1. Goniometer
2. Observation |
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Maintenance of ROM
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- positioning
- orthoses (AFOs) - scar prevention (scar victim's muscles' contract as they heal - AROM is better - PROM |
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ROM treatment
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- Physical Agent Modality = hot packs, paraffin wax
- Active stretches (wall walking, etc) - Activities - PROM (last) - Scar remodeling (shark oil lubricant rubbed in a circular motion) - Orthoses |
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ROM Treatment cont.
PROM |
1. Overpressure =
1) resisting people going into the full arc of their ROM 2) assist to posigion & have them hold it there (great for low ROM) 3) Give them something to resist in a COMPLEX range of motion to make increased ROM 2. Place & hold 3. Push Back |
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2) Muscle Strength
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- ability of muscle to produce tension
- Depends on number and size of muscle fibers - size of fibers increase with tension - Increased activity will result in increased strength (hypertrophy) |
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muscle strength assessment
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1) Manual muscle testing
- First basic test you do 2) Dynamometer - "normal" is determined by bilateral testing and by age/gender 3) Pinch meter |
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Maintenance of Muscle testing
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- active ROM exercises
- Activities * excursive within cycles, which is why endurance exercises create lean, small muscles b/c you don't give them time to grow back bigger |
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Effects of Atrophy on Muscle
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1. Decreased size
2. Decreased strength 3. Decreased mobility |
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Treatments of Muscle weakness
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- Active assistive exercises
- Active exercises - Resistive activities exercises - Muscle contractions (3 types) 1. Concentric 2. Isometric 3. Eccentric |
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Concentric Contractions
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muscle actively shortening (against gravity)
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Isometric Contraction
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Muscle actively held at a fixed length
- muscles fire at different rates to prevent fatigue/lactic acid buildup |
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Eccentric Contraction
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Muscle actively lengthening
ex: pale of paint from high to low |
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Hypertrophy
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= adding muscle bulk/building
- decrease in fiber diameter - muscle soreness due to microscopic tissue damage - Mycrofibrils become torn and damaged when muscles fatigue - Damaged sarcomeres are replaced over time - New (and more) sarcomeres are constructed |
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5 major concepts:
3) Endurance |
= the ability to sustain muscle activity over time
- Involves interaction of variables: a. depends on neuromuscular and cardiopulmonary systems. - Reduced by extended confinement and limitation of activity (8 weeks to completely detail endurance) |
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Endurance assessment
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1. observation = how their handling the activity (hr, strain, sweat, stress)
2. Repetition: increasing repetitions 3. Duration: increasing amount of time involved in an activity |
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Treatment of Endurance
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- increase duration of purposeful activities
- increases repetitions of purposeful activities ** NOTE: the treatments of this FOR are VERY SIMPLE |
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5 major concepts:
4) Structural Stability: 4 postulates |
1. Every peripheral movement creates a shift in the center of gravity that requires a compensatory postural reaction.
2. successful movement requires body structures to function properly and work together to provide stability 3. Simultaneous action = ISOMETRIC 4. Affected by disruption of any components which contribute to joint stability |
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Structural Stability Assesment
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- Observation of positioning and control
ex: unsupported sitting; if you can you get low back wheelchair - Put a child in 1 arm forward, 1 leg backwards |
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Maintenance & treatment of structural stability
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Orthoses
Positioning Rest followed by stress Exercise ex: body builders have weak intrinsic muscles |
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5 major concepts:
Edema |
- Swelling in tissues around the joint
- Limit joint range of motion and movement - Edema control can minimizes the limitation of joint ROM Lymphodema: swollen leg |
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Edema Assessment
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Volumeter = fluid displacement in water (most accurate and easies)
Measuring Tape = good for patients with open wounds |
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Edema Control
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1. Elevation
2. Retrograde Massage 3. Active Mobilization 4. Slight Pressure gloves/garments 5. Temperature Control 6. Contrast baths |
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Structure
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Endurance, ROM, Strength, Structural Stability
All overlapping = function |
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Population
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- applied to individuals who experience limitations that result from problems with:
musculoskeleton system peripheral nervous system integumentary system (skin) Cardiopulmonary system |
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Settings
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= everywere!
- Acute - Sub acute - Pre and Post Surgical - Long term rehab - Home health care |
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Time Frame
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Therapy sessions = 30 to 45 minutes
No specific time frame ( case dependent) |
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Dissemination
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1. Based on well established science
2. No special training 3. No major & expensive tools 4. Can be generalized to a wide variety of cases 5. Can be used across the lifespan 6. Development is predictable: can be generalized |
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Dissemenation cont.
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7. Improvements are rapid and visible
8. Treatment is usually directly pertinent to the nature of the physical injury 9. Quantitative evaluation data = TONS, very easy to measure 10. Supported by evidence based practice!! |
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Limitations
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1) Focus on Physical Dysfunction only
- pain, loss of sensation, and incoordination are not addressed. 2) Does not address permanent losses of function = no CNS injury/recovery 3) Limited application to CNS dysfunction ** DOES NOT address psychosocial issues Doesn't address caregivers No use on TBI or degenerative diseases. |
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DeQuervain's Tensynovitis
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= extensor pollicis longus m. very painful, swelling near lower wrist.
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The Brunnstrom Approach
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History of Brunnstrom
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- By Anna Brunstrom (PT)
- emigrated to the US in the depression - Approach was used in patients with STROKE - designed as a process to eliminate the "trial and error" in therapy ** Master clinician who examined commonalities ** NO one really uses it anymore, but it fed many others |
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Assumptions and principles of Brunstrom approach
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1. Spinal level reflexes can be modified to improve function
2. Primitive reflexes can be used to rehabilitate deficiencies due to stroke 3. Propioreceptive stimuli can change tone or movement patterns 4. recovery follows synergies (common movements after strokes). Must use proper movement to get proper movement 5. Practice must be used to refine movements 6. Practice in context of everyday life enhances the learning process |
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Populations Brunstrom Used
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CVA!!!
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Brunstrom Evaluation
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1. Sensory Testing
2. Tonic Reflexes TLR = Tonic Labrynthine Reflex = arching their head back ATNR = asymetric tonic reflex = muscle man pose STNR = symmetrical tonic reflex = heads up, arms legs in extension OR head flexed, head down (move together) i.e. dog under fence TLR 3. Associated Reactions 4. Limb synergies |
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Flexor Synergy
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- scapular retraction and/or elevation
- shoulder abduction and external rotation - elbow flexion - forearm supination - typically finger flexion - elicited by providing resistance to shoulder flexion or elbow flexion on UNINVOLVED side |
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Flexor Synergy Test
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Test by pressing down on unaffected extended arm and have them oppose movement
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Extensor Synergy
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- scapular protraction
- shoulder horizontal adduction and internal rotation - elbow extension - forearm pronation - wrist extension - finger flexion - excited by horizontal adduction of uninvolved limb |
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Extensor Synergy Test
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SAME!
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(6) Stages of Upper Extremity Recovery
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** MOST IMPORTANT PART OF Brunstrom approach
1) Flacidity - right after 2) Reflexive Synergy - involuntarily 3) Voluntary Synergistic movement - use synergies to complete tasks 4) deviation from basic synergy 5) Independence from basic synergies - where most ppl end up = still awkward and stiff but can still do it 6) Near normalcy with minimal spasticity |
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Rowing Activity
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= what brunstrom was famous for!!!
** Encourages Synergistic Movement!! |
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Levels 1-3 Training synergies
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1) Moving from flaccidity to synergy
2) Percussion or stroking to facilitate contraction - tapping top of humorous or stroking under arm 3) Inhibit antagonist muscles by facilitating the agonist |
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Levels 4-6 training synergies
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4. Deviating from synergy
5. Combine parts of different synergies 6. Work on voluntary movements in and out of synergy |
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Evidence for Brunstrom approach
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- primarily used for strategies for recovery
** Is not used anymore however- the strategies though are still used. |
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The Rood Approach
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** Where pediatrics are based
- Can be used with a grand theory to provide treatment |
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History of Rood APproach
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- Created by margaret Rood (PT/OT) in the 1940s*
- Integrated neurophysiological and ontogenic information with clinical phenomena = after injury, we re-aquire things like children = very much like the Brunstrom approach!! begins with simple movements and gets more complex ** Movements are unique to the Individual - Like the MOHO theory |
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Ontogeny vs. Phylogeny
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Ontogeny = acquisition of complex movements
Phylogeny = higher levels of animals have higher levels of biological complexity - The more complex movements take longer to acquire (humans) ex: crocodiles have very few stimulus patters. |
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Hypothesis for Rood Approach
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Treatment is based on Appropriate stimulus can yield specific motor responses.
= If you apply appropriate Stimulus, client will change response |
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Clients/Settings
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- From acute to long term rehab
- Any motor dysfunction - Across age groups |
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Goals of Rood
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- Normalize muscle tone
- Treatment begins at the developmental level of functioning - Movement is directed towards a purposeful goal - Repitition is necessary for the training of muscular responses ** Must have repetition!! - Begin w/ a chart, start treatment at the level they score. High muscle tone = too many signals Low muscle tones = too few signals |
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Sequence of Motor Development
** IMPORTANT for this FOR |
1) Reciprocal Inhibition = elimination of condition (low or high tone); making the body neutral
2) Co-contraction = flexors and extensors operate at the same time (sitting up right - flex & ext) 3) Heavy work = gross movements that do not require precision, just movement 4) Skill = balancing exhitation, inhibition, very precise movement ex: handwriting |
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Sequence of Motor Development - Static vs. Dynamic movement
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Static =
Reciprocal Inhibition Co-contraction Dynamic= Heavy Work Skill |
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Ontogenic Motor Patterns
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= her recommended body patterns that adults do! Baby picture phases!
1. Supine Withdraw 2. Roll to side-lying 3. Pivot prone 4. Neck co contraction 5. Prone on elbow 6. Quadruped 7. Static Standing 8. Walking |
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Treatmments for Rood
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1) Cutaneous Stimulation = sensory Techniques
- icing - brushing - light touch - fast brushing 2) Propioreceptive Techniques = initiating - heavy joint compression - stretch response = QUICK stretch - intrinsic stretch - Inversion (turned upside down; not done anymore!) - Vestibular stimulation - Tapping - Resistance - Osteopressure |
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Specific Inhibition Techniques
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- neutral warmth
- shaking/rocking in ontogenic sequence (babies on all 4's making children move to challenge these) - Slow stroking - Rolling - Light joint compression (normalizes tone) - Tendon Pressure - Prolonged stretch |
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Fast Stretch vs. Slow stretch
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Fast Stretch = excitatory
Slow stretch = inhibitory |
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Propioreceptive Neuromuscular Facilitation
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PNR!
- Stroke children w/CP & some adult - Evidence is mostly upper neuron |
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History of PNF
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- Founders in California
* Kabat, Kieser & Knott - OT (1974) Dorothy Voss created a course to teach OT/PT at northwestern was big in the 80s, still used today |
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Relavent Treatment Principles
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There are 11 principles
- all humans have undeveloped potential - Normal motor development is proximodistal and cervicocausal*** - Early motor development is reflexive, mature motor behavior is dominated by POSTURAL REFLEX - early motor movement oscillates - development is a sequence of total patterns of movement and posture *** Shares with ROOD REMEMBER: normal development is inside to outside and bottom up |
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Relevant treatment cont.
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- growth of motor behavior evidence by flexed dominance ** Like BRONSTRUM model
- locomotion is dependent on oscillation and postural adjustments (flexion & extension) - Improvements in ability is dependent on motor learning - Frequency of stimulation and repetitive activity are used to promote for retention of motor learning and to develop strength and endurance - Goal direction and facilitation can hasten waking and self care ** Functional activities produce better outcomes than just exercise |
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Auditory System
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Verbal Commands
1. Brief and clear 2. Varied Tones 3. Verbal mediation - complicated wordage does not help learning |
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Visual System
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- Incentives!
= visual goal of what they want to accomplish * something functional |
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Tactile System
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Manual Contacts: Just like Rood
- Stretch - Traction - Approximation = JOINT COMPRESSION *** Unique name to this model! - Maximal Resistance Part and whole task practice ** Uses activity analysis (Like EHP, PEOP) = putting tasks into parts |
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Environment
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- Tasks must be performed in the natural environment
- Evidence supports this & NATURAL environments produce the best outcomes |
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Assessment Sequence
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1. Mose essential functions must be assessed first
2. Head and neck positions are observed a. Dominance of tone b. aligment c. Stability/mobility 3. Upper Trunk 4. Upper Extremities 5. Lower Trunk 6. Lower Extremities |
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1 Words to remember
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Rood = Ontogony
PNF = Diagonals |
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Developmental Patterns and Sequence in assessment
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Patterns of movement are in different sequence of Rood & Brunstrom
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TREATMENT:
DIAGONAL PATTERN (D#) |
= Different patterns of movement for UE, LE & trunk
- Head, neck and trunk patterns - Shoulder and hip D1 Flexion D1 Extension D2 Flexion D2 Extension |
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Unilateral patterns of UE
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UE D1 Flexion and Extension
= flex like gun show = extension with hand up and back like a claw |
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Unilateral Patterns UE
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D2 Flexion/Extension
- Disco move! Flexion = hands open, supine with shoulder & elbow Extension = aDduction, pronation, finger flexion |
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Lower Extremity patters
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D1 Flexion = leg flexed (crossed over knee)
D2 Flexion = leg extended, foot internally rotated, hip flexed |
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Lower Extremity Patterns
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D1 Extension = leg out foot flat
D2 Extension = legs crossed |
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Impact of Service Patterns
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- PNF care can be provided to any motor dysfunction in any setting!
** Most often used on muscle weakness (ROOD is dysfunction rather than strengthening) |
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Client- Centered importance
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* Must use PNF during actual activities, not just movements back and forth
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Documentation of PNF
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DONT talk about D1/2
- Document the functional activity used |
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Lifespan issues of PNF
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- mostly adult populations w/ fractures, tears, muscle pulls/reattachments
- sometimes CVA's ** VERY LITTLE pediatric evidence BUT LOTS OF EVIDENCE OVER ALL |
