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OT-350 MIDTERM SPRING 2011

Most of the exam relates to the 2nd half of the semester, but about 1/4 of it comes from the first half.

**1- __Review PPT on Bb on roles of OTR and COTA in pediatric work__** - basically at COTA can do everything else except initial eval and discharge -train/supervise COTA in administering screening -OTR responsible for scoring and/or interpretation of screening results obtained by COTA -write evaluation / discharge reports -review / co-sign all COTA documentation -on site supervision on regular basis according to COTA experience -can be trained to administer screening test (brief screenings or highly structured test) -should be observed, supervised during learning treatment -collaborate with OTR on developing treatment plan -may carry out most aspects of treatment plan and documentation -documentation of individual treatment progress of each session FJ
 * OTR**: can conduct all aspects of evaluation, treatment planning and treatment
 * COTA:** can't do inital evaluation or discharge

2- __**Evaluation and progress documentation strategies for ADLs and IADLs: both formal evaluations and informal evaluations.**__

ADL- Allows for participation caring for ones own body hygiene eating/dressing/feeding mobility sleep/rest sexual needs IADLS- Activities completed once up and going cooking using computer or phone shopping managing meds play/leisure Analyze occupational performance chose Norm, Criteria, curriculum reference assessments __Criterion__: What skill does the child have with out peer refference __Curriculum__: meeting educational standards __Norm Reff__: How child performs compared to normative sample __Evaluations can be done through__: -interview -inventories -structured observations -top down approach is considered __Instruments of measuremen__t: HELP- measures self care WEE FIM- functional outcomes in self care, mobility Carolina Curriculum- eating, dressing, grooming
 * __Evaluation__**-

__** 3- Feeding **__ **- Normal development of oral structures influencing feeding(P449)** __** Structure Parts (Tramar) **__** Oral Cavity - Hard and soft palate, tongue, fat pads, of cheeks, upper and lower jaws, and teeth **** Pharynx- Base of tongue, buccinator, oropharynx, tendons, and hyoid bone **** Larynx- Epiglottis and false and true vocal folds **** Trachea Tube below the larynx supported by cartilaginous rings **** Esophagus Thin and muscular esophagus **

**- Phases of drinking and feeding process- page 454 (case-smith)** cup-drinking skills don’t emerge until 12months. At 12mo child can position cup to the mouth and to tip it to a degree that decr spillage. 24 mo child child can control flow and may use a cup without a lid. Straw drinking emerges at age 2 (need good lip seal and strong suction to bring liquid into the mouth

- Best positioning for feeding to support optimum head/neck, oral-motor function- **pg 458-460) ** positioning changes may have an immed impact on some difficult oral motor problems such as tonic bite impact & tongue thrust mvmnt pattern. EX. If OT is making positioning adaptations, proximal support (support at the trunk and neck) influences distal mvmnt & control. For this OT should consider positioning throughout childs whole body. Positioning of the feet, legs, & pelvis influences trunk stability. Stability, mms tone, activity in trunk mms affect childs ability to stabilize head and neck. Position & mms activation of head & neck influences jaw mvment. Good jaw stability and freedom of mvmnt influence childs tonge and lip control. Providing ext posture stability, alignment, comfort during feeding optimizes childs oral motor skills and oral intake. Positioning adaptations provide for stability in the trunk and support the child in midline orientation with the head and neck aligned in neutral or slight flex during feeding. positioning shld promote social interaction & comm

**- Handling techniques we learned for supporting oral motor function** **- Health risks associated with oral feeding disorders** **- Altering foods and liquids to make them easier for the child to handle orally-** **(pg 462)** thin liquids presented from open cup are most difficult to control in mouth. Thick, lumpy (oatmeal) require more oral motor strength & sensory tol. Thickened liq is easier to control with lips and tongue allows child more time to organize bolus for effective swallow and without spillage into pharyngeal cavity.

**4- Adolescent to Adult Transition cases; making clinical decisions about the most age-appropriate placement for a young adult with developmental disabilities** OT provides:
 * Comprehensive assessment which is environmentally contextual
 * Direct teaching of skills in context
 * Given client’s skills, altering or selecting a new environment which will be more enabling to the individual
 * Changing or adapting task demands or environmental factors in order to support performance in context
 * Case management and re-evaluation of outcomes

** 5-Handwriting and Components that Contribute to it ** **- What are the visual perceptual, cognitive, and fine motor aspects that contribute to handwriting? What types of handwriting errors could be attributable to impairments in those different aspects?** Handwriting Components: Attention span, lateral preference, lateral dominance, sensory channels, level of perceptual discrimination, motor control, muscular development, presence/absence of immature behaviors, motivation


 * Developmental Component || Contribution to Handwriting || Indications of Problems ||
 * Proprioceptive/Kinesthetic || Perception of hand/body movement and position as hand moves across page || Tight pencil grip, wringing hands, fatigue, student watches hand, slow, mechanical writing, lacks automaticity, breaks tools ||
 * Bilateral Integration || Use of two body sides together in a coordinated manner, one writes and other holds paper stable || Non writing hand inactive, confuses or reverses letters and numbers, avoids diagonal strokes, overflow noted ||
 * Posture/balance || Secure, upright position for coordination of arm, hand, and eye movements || Falls out of chair, slumps against desk, head propped by hands ||
 * Shoulder/wrist stability and mobility || Mobile arm moves hand across page, stable wrist supports arches and allows fingers to move pencil || Flattened hand arches, closed web space, writing not fluid, substitutes shoulder for hand motions ||
 * Tactile || Gives feedback about tool shape, paper and writing surface || Poor legibility of letters, distractible due to aversion to light touch, changes in paper texture or pencil size make a difference in quality ||
 * Motor planning || Sequencing of motor actions to form letters and words || Slow, labored handwriting, awkward grasp, does poorly on timed tests, resist change ||
 * Visual spatial organization || Relationship between letters, words and sentences || Letters cramped or spread out across page, can’t like up math problems or keep consistent margins ||
 * Position in space || Recognition of a letter or number in any position || Reverses numbers and letters, can’t line up math problems correctly ||
 * Visual memory || Ability to recall shape and form of letters and numbers without model || Needs model, legibility poor, spelling errors, same letter written may different ways on page ||
 * Visual discrimination || Perception of shape, size and form of letters || Doesn’t readily recognize errors, inconsistent slant ||
 * Thumb development || Thumb grips pencil opposite first two finget tips, opens web space || Poor pencil group, web space closed, lacks distal manipulative skill ||
 * Hand arches || Shapes hand while holding pencil, allows skilled movement of fingertips || Flat hands, problems gripping tools of different shapes ||
 * In-hand manipulation || Refinement of grasp by shifting and rotating pencil within one hand || Problems rotating pencil to erase, drops pencil frequently, uses two hands to erase or shift grasp ||
 * Motoric separation of the hand || Index, middle and thumb manipulate pencil, ring and little fingers stabilize MP arch || Lacks precision rotation and translation actions with pencil, immature pencil grip ||
 * Eye-hand coordination || Eye movements guide action of hand || Poor execution of letters, colors and writes outside lines, overall problems with legibility ||
 * laterality || Superiority of skill and function of one hand over the other for writing on either side of midline || Inconsistent use of a dominant hand during fine motor and handwriting skills ||

**Motor Control of Upper Extremities** **- Study the presentation I did on Motor Control of Upper Extremity and Hand Function.** **- How do different sensory functions contribute to fine movements of the fingers?** **What are the three main motor control groups that govern shoulder, forearm/ wrist, and hand/fingers, and if you are given cases related to each, be able to identify which one is operating.** **- Know the different patterns of in-hand manipulation, and be able to give examples of each in daily life, when you might use each one?**
 * Type of Sensory Input:
 * Open Loop System: ballistic movements (ie. Throwing a Frisbee), pre-programmed, not changed by sensory feedback once put in motion
 * Closed loop system: small, precise movements of hand and fingers, requires sensory feedback to correct small errors
 * Muscle spindle receptors: coordinate intrinsic and extrinsic muscle forces, provide rapid correction of errors, provide stability for highly mobile fingers
 * Tactile input: update grip force, anesthetizing a thumb interferes with function of muscle stretch reflex
 * Upper Extremity || Motor Control Group || Location/Tract || Function || Lesion Effects ||
 * Proximal Trunk and Shoulder || A || Brainstem – reticular formation, vestibular nuclei, superior colliculi, interstitial nucleus of Cajal || Maintain erect posture, integrate body movements with movements of head and extremities, guide reaching in space || Limbs and trunk in flexion with head slumped and shoulders elevated, unsteady gait, coarse proximal ataxia during reaching (no impairment in agility and speed of hand movement) ||
 * Hand - Extrinsics || B || Brainstem – rubrospinal tract, rubrobulbar tract || Supplements control of Group A, controls independent flexor-biased movements of the extremities, acts on a more restricted number of motor neurons, fewer collateral axon connections ||  ||
 * Hand – intrinsics || Corticospinal || Pyramidal tracts, primary motor cortex, direct connection to motor neurons of hands and fingers || Manipulate objects with fingers || Small movements of forearm, wrist, hand and fingers absent, can only close hand by flexing all fingers together, no precision grip, cannot release object from fingers, no dissociation of individual finger movement ||
 * In hand manipulation:**
 * __Translation – finger to palm__
 * Linear movement of the object from fingers to palm
 * __Translation – palm to finger__
 * Linear movement of the object from palm to fingers
 * __Shift__
 * Linear movement of the object on the finger surface to allow for repositioning of the object relative to the pads of the fingers, ie. Sliding pencil so fingers are closer to tip of pencil
 * __Simple rotation__
 * Turning or rolling of an object held at the finger pads approximately 90 degrees or less, ie. Picking up a pencil that is sitting horizontally and rotating it to use for writing
 * __Complex rotation__
 * Rotation of an object 180 to 360 degrees once, or repetitively, ie. Flipping pencil around to use eraser.

6**- Seating and Positioning/Assistive Tech** **- Review the PPT I posted regarding Seating and Positioning (and p. 640-642)** **-What are key seating angles that need to be considered when fitting a child for wheelchair or other seated positioning device?** - Hip, pelvis, spine - Lower legs - Ankle and foot - Angles of seat to backrest, seat to calf-rest and calf-rest to footrest to influence overall tone **- What are the bony protuberances that would be the most likely pressure points for possible decubiti? (pressure sores)** seat bones, scapula, elbow/wrist **- What are some of the main types of assistive tech devices?** Pencil grips, raised lined paper, post it notes, highlighters, index tabs/page flags, reading strips, dictionary **- What are some of the main types of augmentative communication devices?** Word processors, idea organizing software, word prediction software, reading support software

**7-NDT and Cerebral Palsy** **- What is muscle tone like in the different types of cerebral palsy? How is it different proximally in comparison to more distally in spasticity?**

- Hypotonia - Spasticity - Athetosis - ataxia
 * Mushy, weak, lax ligaments, affects bone growth and density, postural insecurity
 * Without regular activation and elongation, results in muscle shortening, then structural changes, leading to contractures, activate distally instead of proximally
 * Form of dyskinetic CP associated with prominent involuntary posturing and dystonia.
 * Abnormalities of volunatry muscle movement involving balance and position of trunk and limbs in space.

**- What are the different techniques of neuromuscular facilitation (e.g. different speeds of movement, types of muscle tapping, sustained versus intermittent joint compressions, elongation or muscle stretch) and what is their action? What do we mean by “graded handling”? Key points of control?** - Traction/distraction – inhibitory, decrease abnormal tone and movement pattern (if non-rotational); if applied with rotation and movement of extremity, facilitatory - Compression/approximation – pressure applied over the muscle belly, generally inhibiting - Weight bearing – any point of contact with the support surface which supports all or partial body weight, requires neuromuscular activity from more proximal joint segments - Joint mobilization - Passive stretching - Sweeping – moving touch over the skin and muscle, combo of compression and gentle traction, facilitatory - Tapping – moving touch that presses inward, facilitates normal muscle contraction and movement - Vibration – high frequency is facilitatory and low frequency is inhibitory - Deep pressure- used to dec tone and calm. - Shaking – low frequency vibration, applied to proximal joint above segment that needs to be inhibited - Light touch - //Graded handling// – adjusting the touch or pressure and where it is applied so that it is appropriate for the child - //Key points of control// – specific proximal or distal areas on the child’s body selected for therapeutic handling, ie. Head, shoulder, girdle, trunk, pelvis, lower arms, hands, knees, feet

**- What do we mean by an interfering postural movement, or “fixing”, and what are some examples?** In Neurodevelopmental Treatment (NDT), postural control is the foundation on which patients begin to develop their skills. Patients undergoing this treatment typically learn how to control postures and movements and then progress to more difficult ones. Therapists analyze postures and movements and look for any abnormalities that may be present when asked to perform them Examples of common abnormal movement patterns include obligatory synergy patterns. These patterns can be described as the process of trying to perform isolated movement of a particular limb, but triggering the use of other typically uninvolved muscles (when compared to normal movement) in order to achieve movement.

**8-School System OT & Early Intervention; ICF (International Classification of Function)** **- Know all the legislative information of how OT became mandated in the public schools, and as a service in Early Intervention** IDEA act of 1975 guarantees free appropriate education to children with disabilities. Part C of the act provides legislative support for family early intervention services for children age 0-3 years.

**- Rules about placing a child with a disability in a special classroom;**

The school cannot place a child in a restrictive environment unless they can prove that the disability is severe enough that the child cannot be educated with non-disabled peers.

**- What are the IEP and the IFSP and the differences?**

IEP= for school age children: present levels of education, performance strengths and weakness, goals, services required to meet goals, accommodations, duration and location of services, transition services, measurements of student progress

IFSP= for early intervention: states current level of functioning, family resources, priorities and concerns, states major outcomes, criteria, procedures and timelines, states intervention services, frequency, etc., location (natural environment), projected dates, identification of service coordinator, description of transition plan

**- What does “least restrictive environment” mean, and the law about it?**

The least restrictive environment is the most desirable situation in which the child is to be educated with non-disabled peers with appropriate aids and supports. The school cannot place child in a more restrictive environment unless they can prove that the disability is severe enough that the above cannot be achieved. This falls under the individuals with disabilities act (IDEA).

**- What are the differences between OT under a medical model versus school-based, educational model?**

In the schools, OT must be educationally relevant.

**- Under the International Classification of Function //Environmental Code Set//, what elements of the environment contribute to degrees of disability and handicap of persons?**

???ICF code set: 1- products and technology 2-natural environment and human made changes to the environment 3-support and relationships 4-attitudes 5-services, systems and policies 10 most important environmental risk factors Hx of maternal mental illness high maternal anxiety, rigidity in paternal beliefs and attitudes, few positive maternal-child interactions, heads of households in unskilled occupations, minimal maternal education, disadvantaged minority status, reduced family support systems, stressful life events and large family size This info is found in the ppt titled Models of Development and Developmental Risk from earlier in the semester

**9-NICU** **- There are two PPTs on Bb on this!** **- What are the environmental/sensory elements of the NICU environment which can distress the physiological systems of the high-risk newborn?** - Tactile - Vestibular - Motor - Auditory - Visual - **What does the literature say about the positive effects of parent(s) being able to be in the NICU with their baby on a daily basis?** - Physiological and developmental benefits - Parents learn therapeutic positioning, handling, sensory input to avoid, learn kangaroo care - Help parents to learn, observe, interpret and respond appropriately to infant’s uniqie signals and behaviors
 * Dry, cool, inconsistent touching is intrusive and painful
 * Horizontal, flat, static, unprotected from gravity
 * May be passively extended, lack of flexor support, often placed in supine, may be restrained, unable to move hands to face/mouth
 * Very loud, harsh, constant mechanical noise
 * Bright fluorescent lights, invasive ophthalmic procedures

**- What are the positive effects of prone or sidelying positioning on a high-risk newborn, versus lying in flat supine?** - Prone - Sidelying
 * Increase oxygen
 * Increase lung compliance
 * Increase tidal volume
 * Increase postural security when trunk and extremity flexion is facilitated
 * Reduces extensor effects of gravity
 * Promotes midline orientation of head and extremities, encourages hand to mouth/face activity

**- What are the components of the theory of “synactive development” proposed by Dr. Heidelise Als, that are the infant’s way of communicating with us signs of stability and approachability, versus stress and defense?** Stability and approachability - Autonomic stability (smooth respirations, pink, stable digestion, absence of stress signals) - Motoric stability (smooth, well-modulated posture, synchronous movements of hand clasping foot/hand to mouth/grasping/rooting) - State stability and attentional regulation (clear, robust sleep state, rhythmical crying, effective self-quieting, reliable consolability, focused, shiny-eyed, animated facial expressions) Stress and Defense - Autonomic (seizures, tremors, irregular respiration, color changes, yawning, hiccupping, gagging, sneezing, coughing) - Motoris stress (increasing facial, truncal, extremity flaccidity, increasing hypertonicity, finger splaying, tongue protrusion, hyperflexion, frantic - State related stress signs (diffuse sleep, whimpering sounds, eye floating, staring, active gaze aversion, panicked, hyperalert, glassy-eyed, rapid state oscillations, irritability, crying, frenzy, inconsolable, sleepless, restless)

**10-Sensory Integration Patterns of Dysfunction:** **-What are they? What are the major characteristics of each?**
 * Sensory modulation disorder
 * problem regulating neuronal thresholds to sensation (threshold too low=hypersensitive, may be sensory avoiding; threshold too high=slow to respond, may be sensory seeking)
 * Postural-ocular and bilateral integration
 * Poor prone extension
 * Poor antigravity neck flexion
 * Hypotonicity
 * Poor proximal joint stability
 * Inadequate postural background movements
 * Poor equilibrium
 * Postural insecurity
 * Poor kinesthetic perception
 * Depressed post-rotary nystagmus
 * Difficulty mastering play skills
 * Poor performance in sports
 * Directional confusion
 * Problems with construction oriented play requiring smooth bilateral hand use
 * Low tone, sluggish, lethargic
 * Limited play choices – prefer video games, tv and computer
 * Dyspraxia
 * Difficulty planning and organizing though
 * Poor writing and drawing abilities
 * Other fine motor difficulties
 * Difficulty copying from the board
 * Reading and spelling difficulties
 * Clumsiness
 * Prone to accidents
 * Poor hand-eye coordination
 * Slow/poor at dressing
 * Messy with eating and drinking
 * May have speech and language difficulties
 * Poor ideation
 * Perceptual (discrimination) dysfunction

**- What are the four types of sensory** //**modulation disorder**//**, and how does each relate to the concept of higher or lower thresholds of stimulation? How do they relate to levels of arousal (high or low)?**
 * Avoidance – low threshold
 * Sensitivity – low threshold
 * Low registration – high threshold
 * Sensory-seeking – high threshold

**11-What are the four components of the Problem-Oriented Medical Record, (the fancy name for a SOAP note), and what type of information goes in each one?** S-subjective, what the patient says or teacher/parent/caregiver says about a patient, ie. "he is reversing the letter p"O-objective, what you found, ie. writing sample was taken and the letter p was reversed 9 out of 10 times.A-assessment, what do you make of the results?, ie. child has trouble identifying letter position in spaceP-plan, what are you going to do about it?, ie. during OT, child will practice tracing, copying and writing the letter p **12-Applied Behavioral Analysis** **- What are the main strategies for addressing negative behaviors, and under what circumstances would each be used?**
 * Interruption and redirection
 * Interrupts behavior and teaches child what to do and what not to do
 * The reinforcer: escape or self-reinforcing
 * Extinction (ignoring)
 * Stop giving attention to a behavior that has been rewarded in the past
 * The reinforcer: attention and reward
 * Response cost (taking away or eliminating a reinforcer, ie. Time out)
 * Only use for behaviors that occur occasionally, take away something related to the behavior, immediate

**What are the patterns of attachment and characteristics of each?** __Patterns of attachment __: Secure, Avoidant, Resistant/Ambivalent, Disorganized/Disoriented

**13-What are the main types of test validity to look at when evaluating an assessment you are thinking of using? (face validity, construct or concurrent, predictive, test-retest reliability and inter-rater reliability)**
 * Attachment Style || Caregiver Behaviors || Infant Behaviors ||
 * Secure pattern || Emotionally available, timely consistent & effective responsiveness to infant phys & emotional needs || Seeks proximity to parent; w/ increased mobility, explores freely; confident; misses parent but easily comforted ||
 * Avoidant Pattern || Emotionally unavailable; typically not adequately responsive to infant communication of needs || `Avoids parent; emotionally blunted; interacts w/ objects in environment rather than w/ parent ||
 * Resistant/ ambivalent || Inconsistently available & responsive to infant needs; caregiving style determined by parent mood, unpredictable || Clingy; preoccupied w/ parent; does not actively explore environment; difficult to comfort aft separation; mood angry or passive ||
 * <span style="font-family: 'Arial Black','sans-serif'; font-size: 16px;">Disorganized/ disoriented || <span style="font-family: 'Arial Black','sans-serif'; font-size: 16px;">Highly anxious or threatening towards child; doesn’t respond effectively or appropriately to infant; may be abusive or psychotic || <span style="font-family: 'Arial Black','sans-serif'; font-size: 16px;">Disorg’d or disoriented when interacting w/ parent; approach-avoidant behaviors, incl staring, freezing; clinging or huddling on floor ||
 * **Face Validity**
 * **Construct -** the extent to which a test measures a particular theoretic contruct.
 * **Content- Related:** the extent to which the items on a test accurately sample a particular behavior domain.
 * **Criterion Related -** the ability of a test to predict how an individual performs on other measurements or activities.
 * **Concurrent -** how well test scores reflect current performance.
 * **Predictive -** identifies the relationship between a test given in the present and some measure of performance in the future.
 * **Test-Retest Reliability -** a measurement of the stability of a test over time.
 * **Inter-rater Reliability -** the ability of two independent raters to obtain the same scores when scoring the same child simultaneously