Levels of physical activity
Regular physical activity of moderate intensity can bring about major health benefits as well as significant cost savings for the NHS. Increasing levels of physical activity would contribute to achieving reductions in coronary heart disease and obesity, hypertension, depression and anxiety. [subtitle: Be Active, Be Healthy: A Plan For Getting the Nation Moving. Department of Health, 2009. DH Publications, London]
The cost of inactivity for 2006/07 for the Cumbria Primary Care Trust has been estimated at £8,277,950. [subtitle: National Programme Budget Report: Diseases related to Physical Inactivity. WHO.]
Physical activity is associated with reduced risk of depression and dementia in later life, is effective in the treatment of clinical depression and can be as successful as psychotherapy or medication, particularly in the longer term. [subtitle: Barbour KA et al. 2007 J Cardiopulm Rehabil Prev. 2007 27:359].
More generally, physical activity helps people feel better and feel better about themselves, as well as helping to reduce physiological reactions to stress.
Be Active, Be Healthy establishes a new framework for the delivery of physical activity aligned with sport for the period leading up to the London 2012 Olympic Games and Paralympic Games.
People with disabilities are at particular risk from inactivity. The Inclusive Fitness Initiative, with support from Sport England and the English Federation of Disability Sport, is developing accessible and inclusive environments for people with disabilities.
Exercise has general applicabilities over a wide range of client groups. We will illustrate using gym-based exercise as an intervention using a specific case. This particular client was involved in a road traffic accident that has left her paraplegic as her spinal cord was damaged at T9. (could you maybe offer a brief explanation of T9 ie This type of injury occurs in the lower thorax region of the spinal cord, and can result in either complete or incomplete paraplegia, in which the voluntary movement and sensation in the areas of the body below the point of injury are compromised. The hands are not affected, and some function below the point of injury may be retained depending upon the exact location of the injury - that might be a bit too much, but it could always be shortened) She has spent a considerable time in hospital and has recently started to become more mobile with the use of a wheelchair.
We used the Canadian Occupational Performance Measure to identify areas of concern and to determine which kinds of intervention might help Doris to rehabilitate physically and holistically in terms of mental wellbeing.
The Measure highlighted that Doris wanted to be able to pursue the same kind of active lifestyle she had prior to the accident: Doris enjoyed working on particular equipment in the gym such as the cross-trainer, the treadmill and the rowing machine.
The Activities Health model was used to assess progress.
For people in wheelchairs who retain full upper body mobility, a wealth of different exercises are available from which to choose which will keep the back, shoulders, arms and chest fully fit. Unfortunately, universal machines are not designed with wheelchairs in mind, making many of the exercises difficult, if not impossible. While the number of exercises one can perform from a wheelchair on a standard universal are limited, there are at least two that can be utilised. Mike Haynes, a specialist trainer at St. David's Wheelchair Fitness Program, explains that paraplegics and quadriplegics frequently lose muscle tone in their back and rear shoulder muscles. The remedy, then, is to strengthen the muscles of the upper, mid and lower back and rear shoulders, in order to tighten up the posture. One exercise that can be practised is resistance training, using large stretchy rubber bands that are called resistance bands. You take the bands and wrap them securely around a stable object such as a door, or the arm of your wheelchair. Pull the bands towards you and then the other way away from you to give your muscles a good workout. Rubber bands can be used for pull-downs, shoulder rotations and arm and leg extensions. The other exercise is strength training. Strength training uses the lifting of 'free weights' or dumbbells. A typical weightlifting routine should be performed at least three times a week, on alternating days, without exercising the same muscle areas two workouts in a row.
For those in a wheelchair, what differs in regards to using a universal machine is the choice of what areas to work and stretch. Specifically, those with spinal cord injury tend to get frontal shoulder tightness from continually pushing their wheelchair. This creates a situation where the front shoulder muscles become stronger, while opposing muscles in the upper back and back of the shoulder weaken. This can be overcome by ensuring that you stretch the front shoulder muscles regularly, and exercise the upper back and back shoulders by doing seated rows and wheeling your chair backward..
An initial assessment was carried out to determine feasibility of the intervention in terms of access etc. The OT went to the gym with Doris. Access was via a fairly steep ramp that Doris had difficulty negotiating as she has only recently started using the wheelchair. The first door into the building is automatic and easily negotiated. The secure access door was very awkward to use, as the swipe reader was at a distance from the door itself and the door was very narrow; both wheels of the wheelchair touched the sides of the door on entry. This could lead to feelings of inadequacy and make it more likely that people might offer help that is not wanted. Doris needed to feel as independent as possible if the intervention was to work on more levels than simply improving fitness.
Disabled facilities at the gym include a disabled toilet with integrated shower. This appeared on first inspection to be OK; however, the controls and shower head were positioned too high for the wheelchair user to reach and there was no seat provided for transfer into during showering. Doris was determined that she should be able to use the gym as normally as possible and wanted to be able to shower immediately after exercising. The space provided for changing and temporary storage of clothes was also inadequate. Doris required specific facilities, e.g. a chair-level transferable bench to permit her to change into her gym kit independently.
Health and Safety
The second objective for this visit was to carry out an active risk assessment. Several risks were identified: The access ramp may have been within regulations for gradient, however, particularly for a new wheelchair user the grade was very steep and the turn was too sharp for the chair. Thus, route of access was difficult as the wheelchair tended to run away down the ramp. The OT was needed to control the chair to avoid injury. Getting up the ramp after exercising would also be a challenge, particularly in the early stages of Doris' rehabilitation, as mobilising up the ramp was a significant effort. Doris' mobility control should improve with practice; however, the regulation gradients of access ramps may actually be too steep for some situations. Overhead lighting was very limited, so negotiating the ramp during hours of darkness - inevitable in the winter - would be dangerous. Floor-level lighting was built in to the wall, but was broken and non-functional. This required to be replaced. The lack of lighting would make any user feel vulnerable and therefore less likely to use the gym. The swipe card reader was positioned such that there was a possible risk of overextension of the shoulder joint or even possible back injury. This problem was exacerbated by the door, which had to be opened within a short timeframe of swiping the card and was very heavy, spring-loaded and at an awkward angle. Inside the door a cross-trainer was positioned such that it was very difficult to move inside the gym whilst holding the heavy door open. Moving around the gym was not a problem, however, general safety concerns regarding equipment use needed to be addressed. These include: Pins not completely inserted into weight stack; standing too close when the lateral bar is in use. The cable pulley, which was identified as the most useful piece of equipment for Doris to use, was positioned directly adjacent to the free weights area. There is therefore a risk of injury to anyone using the cable pulley if the weightlifter loses control of the barbell and needs to jettison the load. Doris is particularly vulnerable to this possibility as she would need to use the cable pulley from a distance and would therefore be outside the protective bars around it. Possibly, directives should be put in place asking that people refrain from using the barbells while someone is using the cable pulley. Gym policy states that anyone using the barbells should be 'spotted' by a buddy to prevent such accidents.
Access into the disabled changing room itself was also hampered by the heavy, spring-loaded door. An emergency pull cord was provided and was in an easily accessible position.
The shower, as previously mentioned, had no purpose-built seat. A free-standing chair would present an unacceptable risk to a paraplegic client attempting to shower independently. A seat adapted for this particular client would need to be fitted.
Theft was determined to be a risk to the client; lockers were available but were awkward to access from a wheelchair. No facility for securing valuables was available in the disabled changing room itself; this would also need to be provided.
Lifting weights from the stand in a sitting position may present a risk of injury - the client should be instructed in how to correctly lift weights to minimise the risk.
Health service restructuring supports collaborative interaction. Jones et al (1997) noted that contemporary collaboration is very different from the hierarchical interactions that pervaded hospital bureaucracies in the past.
The roles of different professional contributors, a communication strategy and a joint objective are emphasised as the most significant factors underpinning successful teamwork.
Subtitle: McCallin, A. 2001 Interdisciplinary practice - a matter of teamwork: an integrated literature review. J. Clin Nursing 2001 10:419-428
OTs are required to consult with other service providers when they feel that additional knowledge, expertise and support are needed. They recognise the need for multi-professional collaboration to ensure that clients receive the most effective intervention.
Subtitle: COT 2005 Code of Ethics and Professional Conduct.
OCCUPATIONAL THERAPY WITHIN THE INTERDISCIPLINARY TEAM
Occupational therapists typically work as team members, whether in clinical mental health or psychosocial rehabilitation services, providing occupational therapy-specific services, case management, program coordination and management in these settings. Specific contributions of occupational therapists that reflect their occupational perspective may be briefly illustrated through discussion of functional assessment and skill development. Occupational therapists frequently undertake functional assessments, contributing information to the interdisciplinary team's knowledge and understanding of consumers' situations and functioning. So, in interdisciplinary teamwork, occupational therapy assessments help address questions about how persons are functioning in daily life, their support requirements, and contribute to other aspects of clinical decision-making.
Effective interdisciplinary teamwork: an occupational therapy perspective - Australasian psychiatry Vol 9, No 3, September 2001
A meeting was convened between the OT, Doris' physiotherapist, a sports therapist and a representative from university Estates to discuss adaptations required and the kind of exercises that would be most appropriate for Doris to build up her fitness and stamina.
The estates representative was consulted regarding changes needed to access and facilities at the gym. Here the objective was clear in that the gym door required widening and adapting for disabled access. The disabled showering facility also needed to be altered with seating and secure storage provided. Budgetary restrictions were cited, meaning that no action could be taken until the next financial year. This conflict was partially resolved by suggesting that some emergency finances might be available and referring the representative to funding from the English Federation of Disability Sport. The estates representative was asked to leave the meeting at this point for reasons of patient confidentiality. This enabled the allied health professionals to discuss Doris' case in detail. The OT had adopted the role of team leader but the meeting now became more informal as each individual had their own professional contributions to make.
Since Doris can no longer use her legs she has had to adapt her exercises with the help of her OT and is now focusing on exercises to strengthen her upper body, arms and back to facilitate wheelchair mobility as well as restoring her cardio-vascular fitness. She was shown how to use a multi-pulley cable machine in several different configurations to help strengthen the shoulder joint, back and arms. The shoulder joint is particularly important in wheelchair users because the upper extremities are used for wheeling, transfers and activities of daily living; injury through overuse is particularly common. [subtitle: Muscles: subscapularis, supraspinatus, infraspinatus, teres minor]. The use of these machines makes grading the exercise very straight-forward as weights can be added as strength increases. Doris also used small dumb-bells to strengthen her arms.
Eventually, Doris felt that her fitness levels and mobility skills had been developed sufficiently to invest in a sports wheelchair. This increased her mobility to the point where she could engage in a sport she had previously enjoyed, but had given up thinking about due to her disability. The sports chair coupled with the exercise intervention resulted in the ability as well as the self-confidence to resume playing basketball, which was her favourite sport before the accident.
The team's joint objective was to enable Doris to use as many of the facilities of the gym as she was physically able to. Restraints experienced including the changing facilities and access in and around the gym not only placed physical stress on her but also mental stress, affecting her performance and wellbeing. Regarding Doris' interest in basketball, the OT offered to contact an athlete with a disability (preferably a wheelchair basketball player) to demonstrate that she can still be active, and by having a role model will encourage Doris to become more self-confident. Strengthening Doris' upper body by having her engage in ADL tasks as well as using light weights and resistive bands will encourage her gross and fine motor coordination skills. Whilst the OT can address ADL tasks and equipment, it would be better to refer Doris to a wheelchair specialist to prescribe a custom chair. Concerning the gym facilities, the OT's therapy sessions will consist of grooming and dressing with adaptive equipment, increasing upper extremity strength, increasing tolerance to activity, and practicing transfers from all surfaces and planes.
Occupational therapy for physical dysfunction Sixth Edition 2007 - By Mary Vining Radomski, Catherine A. Trombly Latham
The OT offered encouragement and general support to keep Doris' morale high and she soon became proficient in mobilising in the sports chair. From this point on, she made rapid, independent progress.
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