(Lynne Sandles (Auth.) ) Occupational Therapy in RH (B-Ok - Xyz)
(Lynne Sandles (Auth.) ) Occupational Therapy in RH (B-Ok - Xyz)
(Lynne Sandles (Auth.) ) Occupational Therapy in RH (B-Ok - Xyz)
FORTHCOMING TITLES
LYNNE SANDLES
Principal Occupational Therapist
The Dene Centre
Newcastle-upon-Tyne Council for the Disabled
Acknowledgements ix
Preface xi
I Introduction to chronic arthritides 1
2 Psychosocial aspects of rheumatoid disease 14
3 An holistic approach to the management of rheumatoid
disease 41
4 Assessment 51
5 Developing skills 72
6 Adaptive techniques 103
7 Housing adaptation 147
8 Splinting 162
9 Relaxation and pain control 170
10 Personal and sexual relationships 177
11 Community care 184
References 192
Index 195
Acknowledgements
The completion of this book has been achieved with the support,
advice and contributions of many people. I would like to express my
thanks to all those who have been involved in any way. Special
thanks go to Jo Campling and Chapman and Hall and to Helen Jones
for her endless patience and help.
This book would not, however, have been written without the
people of the North East of England who have shared freely their
experiences, their humour and made me welcome in their homes.
They are the people from whom I have learnt rheumatology and I
dedicate this book to them.
Preface
1
INTRODUCTION TO CHRONIC ARTHRITIDES
Fibrous capsule
2
TYPES OF CHRONIC ARTHRITIS
1stMTP
Osteoarthritis
3
INTRODUCTION TO CHRONIC ARTHRITIDES
4
TYPES OF CHRONIC ARTHRITIS
MTPs
5
INTRODUCfION TO CHRONIC ARTHRITIDES
1. Systemic
(a) Rheumatoid nodules
(b) Sjogren's syndrome
(c) Anaemia
(d) Lymphadenopathy
(e) Amyloidosis
(f) Vasculitis;
2. Ocular
(a) Scleritis and episcleritis;
3. Neurological
(a) Peripheral nerve entrapment
(b) Cervical cord compression
(c) Peripheral neuropathy;
4. Pulmonary
(a) Pleurisy
(b) Pleural effusion
(c) Pulmonary fibrosis;
5. Cardiovascular
(a) Pericarditis and myocarditis
(b) Pericardial effusion.
6
TYPES OF CHRONIC ARTHRITIS
7
INTRODUCTION TO CHRONIC ARTHRITIDES
8
TYPES OF CHRONIC ARTHRITIS
1. Ocular
(a) Uveitis and conjunctivitis;
2. Pulmonary
(a) Upper lobe fibrosis;
3. Cardiovascular
(a) Aortic regurgitation
(b) Conduction defects;
4. Neurological
(a) Nerve root or cord compression;
5. Systemic
(a) Amyloidosis.
9
INTRODUCTION TO CHRONIC ARTHRITIDES
10
LABORATORY AND RADIOLOGICAL ASSESSMENTS
11
INTRODUCTION TO CHRONIC ARTHRITIDES
Radiological investigation
SUMMARY
12
FURTHER READING
FURTHER READING
R. Cailliet (1982) Soft Tissue Pain and Disability, F.A. Davis Company,
1.S. Pigg, P.W. Driscoll, R. Caniff (1985) Rheumatology Nursing, A
Problem Orientated Approach, Wiley Medical Publications.
G.K. Riggs, E. Gall (1984) Rheumatic Diseases, Rehabilitation and
Management, Butterworth Publishers, Guildford.
13
2
Psychosocial aspects of rheumatoid
disease
14
SELF-CONCEPT
SELF-CONCEPT
Self-image
Self-image refers to the way we perceive our body looks and func-
tions and the emotions that our body generates, therefore it has both
a visual and an emotive element. The body schema, or visual map,
is developed in early childhood and represents the development of a
physical image, this image develops throughout life as our body
undergoes change, especially during such periods as adolescence. As
this physical picture is developing an emotional component is
developing alongside it. The emotional component is influenced
15
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
16
SELF-CONCEPT
Disease process
17
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
same as those held by the client and attention to detail may not be
as great. Clients whose mobility has become impaired may be reliant
upon members of the family or other carers to buy clothes, make-up
etc. on their behalf, losing control, to some extent, over the image
which they wish to project. Clients with limited upper limb function
may be unable to style hair or apply make-up and feel that the ability
of their husbands to assist in these matters is limited. Environmental
barriers may make access to hairdressers, dentists, health clubs etc.
impossible.
The development of deformities such as swan neck and bouton-
niers deformities and ulnar drift are difficult to conceal and gait may
be affected by lower limb deformities such as fixed flexion and
valgus deformities of the knees. The development of deformities can
lead to a change in a person's self-image as they can feel their defor-
mities to be very apparent and attracting unwanted attention. This
can lead to withdrawal from social situations and alterations in
interpersonal relationships.
The. degree of distress a person feels about changes in their
appearance does not necessarily correlate with the degree of deform-
ity they have developed. What may be perceived by one person to
be a mild deformity which causes little stress may be perceived by
someone else as unacceptable and be the cause of much stress. A
young woman attending a self-management course was extremely
distressed by the sight of other peoples' hands within the group. She
was a telephonist receptionist and was desperate to do anything
which may prevent deformities developing in her hands. Other group
members did not all share her concern and were more worried by
some of the other implications of the disease. She found the confron-
tation with other group member's deformity so distressing that she
felt unable to attend more than the first session. Her priority was to
seek assurance that her hands would not become deformed and she
was desperate to do anything possible to prevent deformities
occurring.
Non-verbal communication is an important aspect of any inter-
action providing information, cues and feedback and is fundamental
to communication. The impact of deformity on non-verbal communi-
cation has not been addressed in relation to rheumatoid disease but
is worth considering. Hands are an essential component of the
communication process adding graphic detail to language, providing
a visual portrayal of emotions such as anger, frustration and anxiety,
and via touch expressing affection and providing sensory stimulation.
A person who feels their hands to be unsightly and incapable of
18
SELF-CONCEPT
Treatment programmes
19
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
Perceptions
20
SELF-CONCEPT
21
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
I have never seen what I can look like when I am struggling to stand
up or do something. On the inside, to me, I look no different than
I ever have done and forget that other people can see the reality
rather than my fantasy - I am on the inside looking out.'
The same client provided a graphic description of how she had
tried to cope with accepting that her legs were no longer going to
function in the way in which they used to. She had been very sport-
ing and active and was trying to come to terms with having to use
a wheelchair for long distances, an altered gait and poor balance.
I had heard that one way of dealing with this change was to go
on an imaginary journey to a harbour of acceptance and to stand
on the harbour wall and formally say goodbye to whatever it
was that you had lost, that way you could start to come to terms
with that loss. I can remember the instant well because I was
travelling back to Newcastle on the train from London and so
had nothing else to do. I closed my eyes and imagined my legs
doing all the things I used to value and enjoy and then boarded
those images onto the ship waiting at the quayside. I then sat
and watched it sail away taking those images with it. All this
probably sounds really weird but it really did help to have once
and for all have said goodbye and to stop struggling to hang on
to something I knew I had lost. That doesn't mean that I don't
still miss them but at the time I think it helped.
22
CHANGES IN ROLE
CHANGES IN ROLE
Work roles become incorporated into self-image during the late teens
and early twenties when work becomes a part of daily life for most
people. Work provides a structure and routine to the day, a
challenge in terms of planning a career and providing goals to aim
23
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
24
CHANGES IN ROLE
25
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
26
CHANGES IN ROLE
adopts a new role the role of the other family members may have
to alter to accommodate this change. If role reversal occurs, i.e. the
dominant partner is required to become more passive and the passive
partner is required to become more dominant, stress and anxiety can
be felt by both partners especially if the new role to be adopted is
one in which neither person feels happy or wishes to adopt. The
dynamics of the family will have been altered.
Many roles are socially defined and carry with them a set of
attributes and functions which are perceived as being necessary to
fulfil in order to maintain the role. One example of this is the way
in which the role of 'mother' can be threatened for many women.
After giving birth some women experience a period of increased
disease activity and consequently experience difficulty in caring for
the newly born baby. Feeding, changing and even holding the baby
can be difficult. The emotional turmoil associated with childbirth can
be exacerbated by the inability to care for the baby, in the expected
way, and a dependence upon another family member. If the children
are older they may be required to assist with tasks around the house
or in some situations help with more personal activities such as
bathing or dressing. This may lead a parent to feel guilt as the
children are being asked to give up time which for them may other-
wise have been spent playing or studying and has been expressed as
'denying them their childhood'. These intense emotions associated
with a perceived 'failure' as a parent are often encountered during
discussions. The feeling of guilt is another emotion expressed
frequently in relation to the way families are often the recipients of
bad tempers when clients feel frustrated or in pain.
Isolation can be experienced within the family for a number of
reasons. Pain or sleepless nights may lead to partners sleeping in
separate beds or separate rooms, fatigue or lack of energy may lead
to the client sleeping during the day or in the evening and not going
out as a member of a family so often. Physical isolation can be
experienced through a lessening of physical contact due to increased
pain making hugging painful or fear on the families' behalf of caus-
ing pain. Decreased mobility can mean that clients .may not be able
to join in all the family activities possibly staying at home on some
occasions.
The needs of partners are not always given as much consideration
as they should be, the focus being primarily upon the client.
Misconceptions about the disease can make understanding what is
happening to the client difficult. Anger, resentment and frustration
are also experienced by partners as their plans, hopes for the future
27
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
28
CHANGES IN ROLE
29
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
30
CHANGES IN ROLE
progresses and function deteriorates the effort increases and one way
of coping with this situation is to withdraw from such confrontations
or to cease responding and fighting. By doing this people's social
environment can become smaller and they can become the passive
recipient of societies' prejudices. While it is often said that people
with disabilities are discriminated against no more than any other
minority group and their predicament is similar it must be
remembered that while this may be true, coping with and confront-
ing prejudice is more difficult when you cannot physically gain
access to buildings, when functional ability may be limited and when
energy may be depleted. The extension of a disability into a
handicap is often the result of societal attitudes, values and the
handicapping environment in which we exist.
While aspects of other roles are being lost due to the onset of a
chronic disease one which is being assimilated into self-concept is
that of patient. This role will have different connotations for
different people but is usually equated with being 'sick' and in need
of treatment. The role of patient is reinforced by the environment in
which that role is encountered, i.e. hospitals and doctors' surgeries
and the perceived roles of the people working within that environ-
ment. The environment encountered in many hospitals is rigid,
authoritarian and oppressive and is primarily equipped to deal with
acute illness. When an individual comes into contact with such an
environment it is difficult to adopt anything other than a passive
role. In relation to acute illness this may be appropriate as many
patients are not in a position to participate in what is happening to
them. However, the situation changes in relation to a chronic disease
when clients are not in a life-threatening situation.
A classical example of this, in this country, is the way in which
client's medication is taken away from them as soon as they walk
through the door of a ward. The client has probably been managing,
very successfully, to administer their own medication for the last
five years, but simply by virtue of walking through a doorway is no
longer responsible enough to carry on so doing. Some units have
realized the irrationality behind this and have had to fight extremely
hard to overcome the rigidity of rules governing the administration
of medication. Self-medication on some wards has now been
achieved, but these are still very much in the minority.
31
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
STAGES IN LIFE
The most common time of disease onset is between the ages of thirty
and fifty. To begin to understand the impact of a chronic disease it
is necessary to consider some of the general issues which are being
addressed during these periods of life and may be effected by the
onset of a disease.
32
STAGES IN LIFE
33
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
This period represents the most common age of disease onset and
therefore is the age group most frequently encountered in a
rheumatology department. Development of a chronic disease during
this period can require a reassessment of role in relation to work,
family and society. The prospect of having to give up work can be
devastating, especially as the position reached may represent years
of work. Anger and resentment can be directed towards the fact that,
especially towards the end of this period, children are becoming less
dependent and plans may have been directed towards spending more
time with partners and planning for retirement. These plans may
have to change considerably.
Post-retirement 60 onwards
34
STRESS ANXIETY AND DEPRESSION
35
PSYCHOSOCIAL ASPECTS OF RHEUMATOlD DISEASE
psychological tests that were devised by the investigator and not used
by any other group' (Baum, 1982). The main criticisms of these
studies have been those relating to lack of controls, validity, and
reliability of measures and the retrospective nature of the studies.
Anderson concludes 'there is little or no support for the existence of
an arthritis personality that predates the disease and in some way
leads to the disease onset. Negative personality characteristics are
more feasibly explained as reactions to this chronic disease rather
than a causal factor' (Anderson et at., 1985).
However, an area undergoing research is that of the relationship
of psychological factors and disease activity, especially the effects of
stress. Subjective discussions with clients will often highlight stress
as a cause of an exacerbation in disease activity, and in some
instances as a cause of the disease. In a study carried out by Rimon
two specific sub-groups were identified, a major conflict group
characterized by little or no family history of rheumatoid disease,
severe symptoms and sudden onset, and a non-conflict group, where
there was a higher hereditary predisposition, onset was insiduous and
disease progress was slow. The major conflict group were able to
identify an emotionally traumatic life event within a year before
disease onset and associated subsequent flares with emotional trauma
(Rimon, 1985).
These observations were, however, based upon non-directed inter-
views and could be explained by the process of attribution in which
a client is seeking a causal factor to initiate the disease onset. It
could also be that increased disease activity lowers a client's ability
to cope and as a result of decreased coping higher levels of stress
are experienced. When discussing the relationship of stress to disease
activity the distinction has not as yet been made between a causal
factor or a response and is an area of ongoing research.
The occurrence of depression as a response to chronic illness
should be seen as a normal response and not one necessarily requir-
ing pharmaceutical intervention, unless it reaches the stages of
clinical depression or impairs a client's function. A reactive depres-
sion to loss of function, changes in self-concept and coping with
chronic pain is frequently encountered in clients at some stage in the
course of their disease. The opportunity to discuss these feelings and
to be given support and counselling should be available to clients as
they often feel that their family has reached the point of overload
and they can no longer 'burden them with their problems' so the
availability of another person with whom to express and explore
their feelings is often helpful. This does not necessarily have to be
36
STRESS ANXIETY AND DEPRESSION
Coping strategies
37
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
LOCUS OF CONTROL
38
LOCUS OF CONTROL
39
PSYCHOSOCIAL ASPECTS OF RHEUMATOID DISEASE
FURTHER READING
40
3
An holistic approach to the management
of rheumatoid disease
41
AN HOLISTIC APPROACH TO THE MANAGEMENT OF RHEUMATOID DISEASE
42
THE RELATIONSHIP OF MULTI-DISCIPLINARY TEAMS AND CLIENTS
43
AN HOLISTIC APPROACH TO THE MANAGEMENT OF RHEUMATOID DISEASE
when they arrive. As professionals it is all too easy to adopt the 'I
did explain' approach which usually means that at some point during
a consultation an explanation was given but the client did not under-
stand. An awareness must develop, amongst professionals, of the
feelings experienced by clients when placed in a clinical environment
over which they have little control and at a time when their stress
levels are high. The onus should be placed upon the professional to
create an environment which is less intimidating, ensure that infor-
mation is communicated and to check that this has been understood.
Consideration should also be given to which team member will be
the most effective in communicating information. After a ward round
has passed through a ward more information is usually communi-
cated to clients from nurses returning to talk than at the time the
round has reached the client's bed. Clients can feel so anxious by
the presence of so many people and of being the focus of attention
that they are unable to assimilate what is being said. While
communicating information may be a time consuming process it is
essential if the client is to function as a member of the team.
Access to information and potential resources is to a large degree
controlled by 'professionals' and their perception of what clients
need to know. If the knowledge of the team regarding the resources
available is limited this limitation will be passed on to the client.
While it can be argued that the client has the option to find out infor-
mation for themselves the time, functional ability, energy, and skills
needed to do so are not always present. The barriers to gaining
information are numerous, ranging from the ways in which profes-
sionals can discourage and limit self-help to the format of the infor-
mation once it is identified. As a result of the 1986 Disabled Persons
Act, Local Authorities now have a statutory obligation to provide
information on the services which they provide to clients. No such
statute, as yet, applies to Health Authorities and clients rarely know
how they gain access to dieticians, chiropodists, appliance officers
etc. The same applies to the voluntary sector which is often more
confusing and so clients remain reliant upon clinicians to raise their
awareness of resources which can be used.
The nature of rheumatoid disease necessitates a team approach to
management which is holistic in nature. The needs of the individual
have to be the focus of the clinical team not solely the disease, as
the physical, psychological, social and spiritual make-up of the
individual will determine the way in which they experience and
respond to the disease.
While the central role of the client in their treatment programme
44
THE RELATIONSHIP OF MULTI-DISCIPLINARY TEAMS AND CLIENTS
45
AN HOLISTIC APPROACH TO THE MANAGEMENT OF RHEUMATOID DISEASE
Economic factors
46
THE RELATIONSHIP OF MULTI-DISCIPLINARY TEAMS AND CLIENTS
Social factors
Social factors effect service provision and uptake at two levels, the
allocation of resources and, at an individual level, the uptake of
services. One of the major factors influencing accessibility to or
uptake of services is social class. The inequalities in health care were
highlighted for the first time by the publication in 1980 of the Black
Report which showed how people in lower socioeconomic classes
had less access to services.
Social factors also influence the resources allocated to specific
services and this is especially apparent within the voluntary sector
where individuals are contributing directly to what they perceive to
be needy charities. Priorities for a Social Services Department in
areas of inner cities may be different from the priorities faced by a
Social Services Department in a rural area and thus effect the alloca-
tion of resources.
Political factors
47
AN HOLISTIC APPROACH TO THE MANAGEMENT OF RHEUMATOID DISEASE
following section will look more closely at the role of the occupa-
tional therapist.
48
THE ROLE OF THE OCCUPATIONAL THERAPIST
49
AN HOLISTIC APPROACH TO THE MANAGEMENT OF RHEUMATOID DISEASE
FURTHER READING
50
4
Assessment
51
ASSESSMENT
CLINICAL ASSESSMENTS
52
CLINICAL ASSESSMENTS
Thumb·
U U U U
Index U U U U
Middle. U U U U
Ring U U U U
Little U U U U
Hlp: •
U U
Knee U U U U
Ankle. U U U U
Talocalcaneal • U U U U
Midtarsal: •
U U U U
Metatarsophalangeal
First·
U U U U
Second
U U U U
Third
U U U U
Fourth:
U U U U
Fifth
U U U U
53
ASSESSMENT
Joint tenderness
Musculoskeletal examination
54
CLINICAL ASSESSMENTS
transport on a cold day in the morning for the first visit and is given
a lift in the afternoon for the second visit may show an increase in
range of movement which may not be due totally to therapist
intervention. There is also a degree of inter-observer error with the
use of instruments such as a goniometre, the exact positioning of the
goniometre varying between therapists, so the same therapist should,
wherever possible, complete the assessments.
Functional assessments
55
ASSESSMENT
1. Allow quantification.
2. Have validity.
3. Have reliability.
4. Standardized data collection procedures.
5. Measurement precision (Liang, 1981).
56
CLINICAL ASSESSMENTS
1. the same score for different patients does not indicate that they
are independent in the same activities;
2. two patients might improve equally, by, say, 5 points but one
might move from dependent to partially dependent whilst the
other might move from partially dependent to fully independent
in five activities (Eakin, 1989).
57
ASSESSMENT
58
CLINICAL ASSESSMENTS
59
ASSESSMENT
60
CLINICAL ASSESSMENTS
61
ASSESSMENT
1. Transfers
Chair;
Bed;
Toilet;
Bath.
62
CLINICAL ASSESSMENTS
2. Personal care
Dressing, managing fastenings, shoes, getting clothes from
cupboards and drawers;
Washing face;
Washing body;
Washing hair;
Cleansing after using the toilet;
Application of make-up;
Shaving;
Oral hygiene;
Care of nails;
Combing hair;
Coping with menstrual cycle;
Personal relationships.
3. Mobility
Walking, inside and outside, on rough and smooth surfaces;
Climbing steps and stairs;
Access to house;
Driving;
Using public transport.
4. Home management
Cooking
making a drink;
making a snack;
preparing a meal;
Housework
washing;
ironing;
cleaning;
managing plugs and sockets;
Shopping;
Using taps;
Opening jars, bottles and tins.
5. Eating
Use of cutlery;
Taking cup to mouth.
6. Communication
Writing;
Using a telephone;
Handling money.
7. Employment
Mobility to and from work;
63
ASSESSMENT
PSYCHOLOGICAL ASSESSMENT
64
PSYCHOLOGICAL ASSESSMENT
65
ASSESSMENT
SOCIAL FACTORS
66
THE PROCESS OF OCCUPATIONAL THERAPY ASSESSMENTS
Referral
67
ASSESSMENT
Initial interview
68
THE PROCESS OF OCCUPATIONAL THERAPY ASSESSMENTS
Assessment
69
ASSESSMENT
of the pressures upon the client when undertaking such a visit. The
thought of returning home for an hour's visit, especially after a long
absence, can be extremely frustrating and upsetting. Pressure can be
added by a feeling of having to pass a test before being allowed
home and fear of failure. The amount of activities to be completed
in this time is also unrealistic and demanding and this should be
recognized by the therapist. An imminent discharge can bring a
range of feeling for the client, especially if they live alone, ranging
from happiness and fear to anxiety and loneliness.
Therapists should also consider the implications of the information
obtained during such a visit. The information will help to identify
specific equipment which may be considered within the environment
in which it will be used and to provide an indication of a client's
functional ability in relation to one or two activities. Home
assessments can also provide an opportunity for community support
staff who will be involved in the patient's treatment when discharged
to meet the client and gain some understanding of the problems the
client may be experiencing. Therapists will be all too familiar with
the home assessment where there are so many staff involved that
completing any meaningful assessment of functional ability becomes
impossible. There is a lot to be said for keeping staff to a minimum
and communication being improved by community staff having a
greater involvement in pre-discharge hospital based work.
However, the long-term reality of coping at home cannot be
simulated in such a visit and for this reason post-discharge visits may
be appropriate to ascertain the long-term problems clients may be
experiencing. Admission to hospital, for many clients, represents a
significant reduction in activity. Some clients have expressed dis-
appointment and frustration regarding their level of function and
increase in pain when they have been at home for a few days. Their
level of function has returned to that prior to admission. The feeling
of well-being when laying in a hospital bed can be false and unrealistic
and lead to disappointment and fear a few days after returning home,
for the client and their family. This can be a time when support is felt
to be lacking after the security of a hospital ward where someone,
whether staff or another patient, was usually around to talk with.
The process of assessment is fundamental to the planning of a
treatment programme. It is an information gathering exercise aimed
at building up a picture of the client's physical, psychological and
social needs and then, with the client, placing them in an order of
priority to work towards addressing. In the long-term it will enable
information to be gathered providing a picture of the progression of
70
FURTHER READING
the disease and its impact upon the individual. The format of
assessments is varied, some components of the assessments being
standardized, valid and reliable and others being highly subjective.
The challenge for therapists remains to identify and use standard and
reliable assessments enabling the information collated to be used to
evaluate the effectiveness of interventions. Without the use and
availability of valid and reliable assessment procedures the evaluation
of interventions becomes meaningless. The completion of the assess-
ment procedures enables areas of need to be identified and subse-
quent chapters will discuss interventions used by occupational
therapists to address some of the issues.
FURTHER READING
71
5
Developing skills
72
PROVISION OF INFORMATION
client and the most appropriate way, for that client, in which these
resources can be used. A client with a large social network may seek
support from within this network whereas a client living alone may
join a self-help group to find the same level of support.
The aim of this section is to give consideration to some of the
settings in which information can be communicated and coping skills
developed. The potential use of self-management programmes, self-
help groups and counselling will be discussed.
PROVISION OF INFORMATION
73
DEVELOPING SKILLS
EDUCATIONAL PROGRAMMES
74
CHOOSING APPROPRIATE APPROACHES
end, starts with an overt aim to change behaviour and, at the other
end, finishes with self-help. The role of healthcare professionals
becomes less directive further along the continuum and the aim of
increasing compliance remains very much towards the behaviour
change end of the line. It is therefore essential that the aim of
providing information is clearly identified so that the most
appropriate approach can be identified along with the most
appropriate information provided.
Given a range of information clients will adopt the information and
use the resources which they feel are appropriate to themselves and
their situation, exercising a degree of choice and control. Not
enough work has been carried out to identify what clients perceive
to be important or useful information and which coping strategies are
more commonly adopted than others. The main bulk of studies have
concentrated on the effectiveness of different formats of providing
information, ways of increasing compliance and only in the last few
years, the affect on psychosocial parameters.
The long-term implications of participating in educational
programmes are yet to be identified. While behaviour change has
been noted the duration of this change and the affects on the disease
progress and levels of pain and functional ability remain a matter for
debate. The evaluation of interventions is of paramount importance
in an area where little is known about the effectiveness of treatment.
It is essential therefore when planning a programme that effective
methods of evaluation are identified.
It is also necessary to re<;ognize that many factors influence
behaviour and the provision of information about coping strategies
and treatment regimes does not necessarily equate with the adoption
or use of the information. The perceived appropriateness of the
information, social and economic factors all influence whether a
client will utilize it or not.
75
DEVELOPING SKILLS
76
CHOOSING APPROPRIATE APPROACHES
77
DEVELOPING SKILLS
78
USE OF EDUCATIONAL APPROACHES
79
DEVELOPING SKILLS
80
USE OF EDUCATIONAL APPROACHES
81
DEVELOPING SKILLS
82
USE OF EDUCATIONAL APPROACliES
While these were the overall aims and objectives for the
programme being discussed more specific aims and objectives were
developed for each session included in the programme. These should
identify in a more precise way the aim of each session and the ways
in which it is possible to identify whether or not these aims have
been achieved. The overall aim of the programme will also identify
the most appropriate approach to use. The above aim led to the
development of a programme using an educational approach. A set
programme was established based on identified needs of a represen-
tative group, but the programme was developed to provide scope for
discussion and was flexible, to some extent, in content to meet the
needs of different groupS. However, it was not a client directed
approach as time was not spent on working with each group to iden-
tify their needs and enable them to arrive at the direction they
wished to take. The resources, especially therapist's time, were not
available to use this approach and the programme would have been
only available to a much smaller number of people.
83
DEVELOPING SKILLS
84
USE OF EDUCATIONAL APPROACHES
Content
1. The structure of a synovial joint.
2. The way in which inflammation can effect this structure.
3. Systemic features of rheumatoid disease.
4. Medical management of the disease.
5. Other forms of management, including diet and homeopathy.
Content
1. The rationale behind the use of exercise.
2. The difference between range of movement, isometric and passive
exercises.
3. Demonstration of and participation in a range of movement
programme.
4. Explanation of how and when to use heat and ice.
5. Discussion on swimming and exercises to carry out in water.
Content
1. Explanation of the concept of pacing.
2. Discussion on what is meant by rest, activity and exercise and how
the three can be balanced.
3. Demonstration of some small items of assistive equipment.
4. Discussion on the use of equipment and its provision.
85
DEVEWPING SKILLS
Content
1. Introduction from therapist about coping with pain and loss of
function.
2. Open discussion from group members.
Session 5 relaxation
Aim To provide the opportunity for participants to discuss how they
cope with stress and tension and participate in a period of relaxation.
Content
1. Continuation of previous week's discussion.
2. Discussion on how pain can cause tension.
3. Explanation of what relaxation entails and different methods
relaxation session.
86
THE USE OF DIFFERENT MEDIUMS
Evaluation
87
DEVELOPING SKILLS
Workbooks
88
THE USE OF DIFFERENT MEDIUMS
Books
Tapeslide programmes
Tapes
89
DEVELOPING SKILLS
Videos
Computer programmes
90
SELF-HELP GROUPS
SELF-HELP GROUPS
91
DEVELOPING SKILLS
92
SELF-HELP GROUPS
For some members the groups provide a way in which they can
contribute to solving some of their own problems and so feel more
in control of their disease. As members become more involved in
groups and have attended for a period of time they may gain a sense
of being able to help other people by offering information or
support. The organization of groups lends a degree of formality
which emphasizes the difference between a self-help group and a
group of friends, although some self-help groups also provide a
social function for members outside of the meetings and friendships
develop through contacts met at groups.
Groups also provide services beyond the group meetings, many
Arthritis Care groups organize swimming sessions, some have
welfare officers who visit clients at home and they also offer holiday
accommodation at several places throughout the United Kingdom or
organize group holidays abroad. Other groups concentrate on fund
raising to help pay for research into a specific condition or campaign
to increase public awareness regarding the condition, or political and
social issues arising from it.
Self-help groups exist on two levels, the larger organizations tend
to be national organizations with a head office and employed staff,
producing literature on a national basis, such as Arthritis Care.
These organizations usually have local groups and regional officers
to provide support at a local level and encourage the development of
new groups and initiatives.
Smaller local initiatives exist where a group of people have met and
decided to start their own group, either because a larger group with
which to affiliate does not exist, or, the one that does exist does not
meet the needs as identified by that group who feel an alternative is
necessary. An example of this may be a local group which consists
of an older age group who meet on a purely social basis and a group
of younger people with the same condition who want to find out more
about their disease and actively campaign on specific issues. While
the presenting condition of the clients is the same the needs as iden-
tified by the two groups are completely different. Local groups have
the advantage over national organizations of being in touch with local
needs. The needs of a head office based in London may reflect in no
way the local needs of a group in the north of the country, whose
priorities, needs and resources may be totally different.
The level of participation in group activities varies considerably.
Some members are willing to adopt leadership roles while others
prefer to stay in the background and attend meetings. Some common
problems of self-help groups have been identified as:
93
DEVELOPING SKILLS
94
SELF-HELP GROUPS
Duddy, 1985). It is difficult when asked for help not to take over
and take on responsibilities, especially when used to organizing and
developing projects and perhaps knowing exactly where to go for
assistance and knowing that the tasks could be completed in half the
amount of time simply because you have ready access to the infor-
mation and know ways around and through systems.
In addition to this founder members may still be feeling unsure of
what they are meant to be doing and out of their depth and feel that
a 'professional' will be able to help them overcome their problems.
However if skills are going to be acquired by members, profes-
sionals must resist the temptation to become too involved, even
though it may initially take longer to explain processes rather than
carry them out. Support and advice should be given and practical
assistance if necessary but preferably working alongside members
and not actually taking on the work in isolation. Clients may feel
initially dependent upon healthcare professionals as they are
predominantly seen as service providers and clients as receivers. To
reverse these roles could be threatening for clients whose expecta-
tions of professionals is one of taking the lead and may also be
threatening to professionals who have been used to being in a
. controlling situation. The temptation to dominate, take on too many
tasks and play an organizational role should be resisted.
Various guides and packages have been compiled to assist groups
in establishing themselves. Once a group of people have been iden-
tified as wishing to develop a group many practical issues have to
be considered. Decisions have to be taken as to the aims of the
group, whether to provide information, provide support, organize
campaigns, raise funds or plan social activities. The composition of
the membership has to be identified as to whether it will comprise
purely of people with the problems, or include family and other
interested people. Thought also has to be given to the first meeting
and a suitable venue identified. The accessibility of the venue can
influence greatly the numbers of people getting to the meetings as
can the availability of transport.
The content of the first meeting has to be identified, a format
developed and chairperson elected. In order to maintain the momen-
tum of the first meeting some thought should also be given to the
second meeting so that the venue and topic can be announced and
members feel a sense of continuity. Once these topics have been
addressed the first meeting has to be publicized and potential
members informed. While not being involved directly therapists can
offer support to members trying to establish a group and contacts for
95
DEVELOPING SKILLS
COUNSELLING
96
COUNSELLING
97
DEVELOPING SKILLS
Stage 1
Meeting the client.
Stage 2
The discussion of surface issues.
Stage 3
Revelation of deeper issues.
Stage 4
Ownership of feelings and possible emotional release.
Stage Generation of insight, the client's life is reviewed by them
5
in a different light.
Stage 6 Problem-solving and future planning.
Stage 7 Action by the client.
Stage 8 Disengagement from the counselling relationship by the
client (Burnard, 1989).
98
COUNSELLING
99
DEVELOPING SKILLS
dealing with them and the possible consequences of doing so. This
enables clients to explore options within the safety of the relationship
established with the counsellor and in some situations to try out
possible responses with the counsellor before embarking upon
facilitating change in their own situation.
The processes involved in counselling are described in many
publications which provide exercises to carry out, either on an
individual or group basis and references will be given. The use of
these skills and the provision of space and time for the client to
explore issues within a relatively safe environment is invaluable in
assisting clients to adapt to change. The responsibility remains with
the client and at no time does a counsellor take on the responsibility
for the client's problems, they merely provide an environment in
which problems can be identified, clarified and explored and
responses learned and tried out.
Even if therapists feel that they do not have the time to become
involved in counselling clients the development of counselling skills
will help tremendously in their day to day work. The ability to be
an active listener and to progress a conversation without imposing
values or opinions is a skill which will contribute to the effectiveness
of client/therapist relationships and provide the means to enable
clients to explore the issues which are of importance to them.
Group counselling has also been used in relation to groups of
clients with rheumatoid disease, the counsellor acting as group
facilitator and using the dynamics of the group to identify and
explore issues of relevance to that group. The structure and intention
of such a group is different from a group of clients meeting as a
self-help group, as a counselling group is usually closed, given some
form of direction from the group leader (in relation to facilitating the
group process) and runs for a set period of time.
This section has explored several settings in which therapists can
be involved as a vehicle for communication. The structure of each
setting is different, as is the role of the therapist in each. The aim
of all of these settings is to provide an environment in which clients
are active, if they want to be. They all focus on active participation
and it must be remembered that for some clients this will not be
appropriate. Some clients will wish to adopt a passive role and hand
over the management of their disease to 'the professional'. Thought
must be given as to whether this is due to a lack of skills and
confidence on the client's behalf which could be developed, an
entrenchment in the medical model of care which hands over all
responsibility to the professional as this is their perceived role or a
100
FURTHER READING
person who for various reasons has taken on a passive sick role in
which they are happy.
Access to information, support and resources are essential
components to coping with a chronic disease. The type of each will
vary from client to client, some clients will find their support from
friends in the club, others from a self-help group and others from
within their own home. Some clients will want to find out as much
information as possible about what they can be doing to help
themselves, others will want to know very little.
The aim of a team should be to provide access to a variety of
settings and approaches so that the needs of clients can be met on
a broad spectrum. The active involvement of clients is dependent
upon the attitudes of the therapists and clinicians they meet and the
amount of information they have access to. The role of the team
should be that of enabling clients and providing access to the
services and resources which clients feel are important, supporting
when necessary during times of need and then withdrawing to give
clients the opportunity and space to develop their own skills.
Empowering clients is an issue which to many clinicians is threaten-
ing, primarily as it means relinquishing power as a 'professional' but
in rheumatology the onus has to be on ways in which clients can be
empowered to help themselves.
The potential of occupational therapists to facilitate these
approaches is immense as many of them are central to the underlying
philosophy of the profession and form a significant component of
therapist's training. While some of the concepts may be alien to the
medical model of care and their potential not realized, as yet,
therapists are ideally placed to introduce and implement such
concepts, as a minimum, within their own clinical practice if not on
a wider scale.
The general direction of healthcare is towards greater client
involvement, a move which to some extent has been client led, and
individual therapists must identify the most appropriate model of
working for themselves, with the confidence however, to know that
they have the skills and the hospital and community perspective to
play a central role in a direction which is slowly becoming reality.
FURTHER READING
101
DEVELOPING SKILLS
102
6
Adaptive techniques
103
ADAPTIVE TECHNIQUES
104
ADAPTIVE TECHNIQUES
105
ADAPTNE TECHNIQUES
106
ADAPTIVE TECHNIQUES
Staying in one position for any length of time can lead to stiffness
and pain on movement, clients will often relate how they dread
getting up after they have been sitting for some time as they know
how painful it will be. Therefore changes of position will help to
decrease stiffness. Sustaining a static position can also be a cause of
muscle fatigue and thus transmit stress to underlying ligaments and
related structures.
107
ADAPTNE TECHNIQUES
over into the clinical field. The main basis for using these principles
initially was the reduction of deformity, but there remains a distinct
lack of clinical data to substantiate the use of these principles on this
basis. This is probably due to the enormous number of variables
involved in such a long-term study. Some of these include the
variability in the disease from client to client, the interpretation of
each principle which leaves a great deal of scope for subjectivity,
compliance over a long period of time and the large variation in
clients' functional activities and lifestyles.
The variability of the disease from client to client is immense. In
some clients destruction of joints occurs rapidly after onset necessitat-
ing joint replacement surgery within a relatively short space of time.
Other clients can have the disease for years and while experiencing
pain and other symptoms joint structures remain intact. It would
therefore be difficult to ascribe the development or lack of develop-
ment of deformity to the use of joint protection aside from the under-
lying disease process.
The interpretation of such concepts of rest and exercise and posi-
tions of deformity etc. are at the moment highly subjective. These
terms would have to be defined much more precisely if they were to
be the basis for an evaluative process.
The benefits of using joint protection in relation to the prevention
of deformity, cannot be demonstrated over a short period of time.
Compliance over a period of years would be difficult to sustain,
especially as clients would not be receiving any immediate rein-
forcement.
The large variation in client's lifestyle and level and type of func-
tional activity makes comparison between clients and control groups
difficult. These are some of the problems which make the evaluation
of joint protection in terms of prevention of deformity difficult. It has
been proposed that the objective of joint protection be redefined as
'pain relief, reduction of internal and external stress to the joint, and
decreasing inflammation within the patient's life-style. Success in
obtaining these objectives should be clinically evident', and two possi-
ble definitions of joint protection proposed as being either in relation
to 'preservation of structural components in a biomechanical frame of
reference, with a cause effect relationship-slowing progression of joint
deterioration' or as 'the enhancement of joint utilization in a functional
sense - by avoiding pain and increasing function' (Shapiro-Slonaker,
1984).
One phrase which should be reiterated is 'within the patient's life-
style'. Therapists must ask themselves what is the realistic level of use
108
ADAPTIVE TECHNIQUES
109
ADAPTIVE TECHNIQUES
ENERGY CONSERVATION
110
PACING
1. pacing;
2. forward planning;
3. work simplification.
PACING
Pacing refers to the use of rest, exercise and activity and their rela-
tionship to each other. The basis of communicating this concept lies,
initially in establishing a client's understanding of each. Rest can be
perceived as anything from reading to gardening, i.e. anything which
is not work. Activity and exercise are often combined so that clients
will perceive doing activities of daily living as exercise and therefore
see no need to carry out a regular programme of exercise. By
understanding the role of each of these three concepts clients will be
able to use them to achieve a balance according to their varying
needs and disease activity. The proportion of each will vary accord-
ing to disease activity and to some extent the client's previous use
of each before disease onset. Some people find sitting down and
relaxing very difficult, preferring to be on the move. To suddenly
incorporate rest into such a life-style can be difficult.
Rest may be applied to one specific joint, being local, the whole
body, often called systemic, and psychological which includes relax-
ation. Local rest refers to the resting of a specific joint due to an
increase in inflammation. It is usually achieved by the use of splints
such as resting splints for the hands and wrists. Systemic rest refers
to total body rest and this is sometimes used during periods of
exacerbation when a client is admitted to a unit for a period of bed
rest. The interpretation and use of bed rest varies from unit to unit.
In some instances it will mean complete rest with clients being
wheeled to the toilet for a period of, on average seven to ten days,
while in others it will mean alternating between bed and chair with
some degree of mobility allowed. Even during periods of complete
rest some degree of exercise will be carried out in the form of
passive exercise or gentle range of movement exercise. Emotional
rest refers to relaxation of the mind. A person may be physically
resting but emotionally active thinking of the tasks which need to be
completed next or feeling guilty about sitting down in the middle of
the day. If the mind is active and stressed muscles will be tense and
the benefits of rest decreased. Relaxation can be used to cope with
111
ADAPTIVE TECHNIQUES
112
PACING
113
ADAPTIVE TECHNIQUES
FORWARD PLANNING
114
FORWARD PLANNING
115
ADAPTIVE TECHNIQUES
WORK SIMPLIFICATION
This is based upon the use of activity analysis and ergonomics and
aims to increase the efficiency with which specific activities are
carried out. Working environments, especially in the home, may not
be laid out in the most efficient way. By asking a client to map out
the distances walked while carrying out a simple task like making a
cup of tea a visual picture of working practice can be made. From
this it may be possible to discuss ways in which changes can be
made to decrease unnecessary activity.
While many of the principles used seem common sense it is often
these which are overlooked and yet they are in many cases, the most
relevant and applicable. They include the following:
116
THE USE OF ASSISTNE EQUIPMENT
117
ADAPTIVE TECHNIQUES
appropriate piece of equipment for the client, these factors are physical,
psychological, social and environmental. The process of assessment for
equipment can be broken down into the following stages.
118
IDENTIFYING THE CLIENTS' NEEDS
• pain;
• loss of movement;
• fatigue;
• weakness;
• stiffness;
• deformity.
119
ADAPTNE TECHNIQUES
120
IDENTIFYING THE CLIENTS' NEEDS
121
ADAPTIVE TECHNIQUES
122
IDENTIFYING THE CLIENTS' NEEDS
Identifying equipment
123
ADAPTIVE TECHNIQUES
Seating
Considerations
- the possibility of adapting existing chair;
- the amount of assistance needed to rise, will extra height be
enough is spring assistance needed or a motorized chair raise;
- the dimensions required, height, depth, width of seat, length of
back;
- accommodation of any deformity, scoliosis, flexion contractures
etc.;
- if mechanical, the method of control and ease of use of controls.
124
COMMON FUNCTIONAL PROBLEMS
Range of equipment
Adapting existing chair Clients who have problems in rising from
a chair will try frequently to increase the height by placing several
cushions on the seat. While this achieves a heightened seat it
completely alters the dimension of the seat raising the seat and
usually making the arms too low to rest on. If the chair offered any
lumbar support this will now be in the wrong place and support for
the head and neck may also be lost. It is more appropriate to raise
the chair from the base rather than the seat.
Chair raisers can be purchased which heighten the chair either by
inserting the legs into a sleeve or by replacing castors with screw-in
legs. A platform can also be built which raises the chair the
required height and into which the castors sink to avoid slipping
when the client sits down. If a seat sags placing a piece of hard
board under the cushion may provide extra support.
Neck cushions can be made or purchased to provide support to
painful necks. Lumbar cushions can prove useful to people with low
back pain, these are usually in the form of foam wedges or
inflatable cushions.
125
ADAPTIVE TECHNIQUES
A good grip on the end of the armrest will also assist in transferring.
There are a wide variety of chairs on the market, many of which are
made to specific dimensions and some of which can be made to the
requirements of the individual client.
Self-lift seats If, having tried a chair which is the correct height,
the client still has difficulty in transferring it will be necessary to
consider an assistive mechanism. Self-lift chairs provide a sprung
seat which assists the client to stand. It is necessary to assess the seat
the same way as above, ensuring the dimensions are correct and then
to assess the strength of spring needed. Some chairs are adjusted by
adding or removing springs from the seat, others have gauges which
can be altered and some are set at the time of purchase by the
manufacturer. The spring is set according to the client's weight.
When they are seated the back of the seat should be flat. If the seat
is not flat the spring is too heavy and should be decreased. If when
the client goes to stand they feel they are getting no assistance the
spring could be increased.
Some self-lift seats have a locking mechanism so that the seat
remains flat until the mechanism is released. This ensures that if a
client is sitting and, for example, reaches forward to pick something
up from the floor the seat does not move and push them forward.
While this extra safety factor is beneficial the mechanisms are often
too stiff for clients with weak grip to operate.
126
COMMON FUNCTIONAL PROBLEMS
Bathing
• Transfers;
• Personal hygiene;
• Comfort.
Considerations
- client's functional ability;
- type of bath, size and layout of bathroom;
- availability of assistance;
- requirements of other family members;
- presence of nodules or leg ulcers;
- post-operative precautions.
Bathboards and seats Bathboards and seats are usually the first
consideration for therapists. The range on the market varies
considerably in materials and fixing mechanism but all basically
fulfil the same function. Boards are used frequently to assist clients
127
ADAPTIVE TECHNIQUES
in getting into the bath, by sitting on the board and swinging legs
over into the bath. Painful metatarsal heads can make standing on
the floor in bare feet painful and this can affect balance, therefore
if clients can transfer sitting down they may experience less pain and
be more stable.
Boards are used frequently in combination with an overbath
shower enabling clients to shower seated. Boards which rest upon
the top of the bath however can cause some problems as tucking the
shower curtain inside the bath is difficult. Some boards and seats can
be wall mounted enabling shower curtains to hang normally but, this
is dependent upon the structure of the wall and the weight of the
client. Boards should always be fitted securely to prevent slippage
when the client transfers.
Seats vary in design and style but, used in combination with a
board, enable clients to get further into the water. Clients with
rheumatoid disease find frequently that lowering from the board to
the seat requires more strength than they have in their upper limbs.
The fabric of the bath is important when considering the type of
seat as fibreglass baths cannot cope with pressure from the seat
being placed on their sides and there is a possibility that they may
crack. Seats with supports that hang on the top of the bath are
recommended for use in plastic baths.
The use of board and seat, while assisting clients to get over the
bath, does have limitations caused primarily by the strength required
to use them and the amount of strain placed through upper limbs.
They do not get the client right down into the water, only allowing
them to perch just above or just get below the level of the water.
Some clients undoubtedly gain relief from pain and stiffness by soak-
ing in warm water and this cannot be achieved by the use of board
and seat.
128
COMMON FUNCTIONAL PROBLEMS
129
ADAPTIVE TECHNIQUES
Overhead and mobile hoists Clients who are more severely disabled
may not be able to give any assistance in transferring and considera-
tion should be given to either overhead or mobile hoists, used in
combination with slings, to assist the carer. The use of mobile hoists
can sometimes be limited in a bathroom due to a lack of space. To
enable a mobile hoist to be positioned a section usually has to be
removed from the bottom of the side panel of the bath so that the
hoist can be pushed underneath. Mobile hoists do have the advantage
of portability to assist with all transfers.
Slings are supportive and the hoists can lift up to an average of
twenty stone with little effort on the carer's behalf. In a ward situa-
tion or in a client's home where all transfers are a problem a mobile
hoist is more flexible as it can be used to assist with all transfers,
whereas a ceiling-mounted hoist can only be used in the position in
which it has been fixed. The design of quickfit slings requires very
little movement of the client to position the sling and they can be
positioned while the client is seated in a chair, whereas the more
supportive hammock slings need to be positioned while the client is
lying on a bed. There are a range of slings to use in combination
with hoists, some canvas and some netting.
With much of the above equipment, except the winding mechanisms
and hoists, the client when seated has to lift their legs over the bath
and pivot round. If a client cannot do this easily, thought should be
given to the stretch being applied to the skin on the client's bottom
if twisted round by a carer. Torque and shear can easily cause a tear
in fragile skin which may then develop into a pressure sore.
Personal hygiene
130
COMMON FUNCTIONAL PROBLEMS
Toilets
• transferring;
• cleansing after using the toilet;
• flushing the toilet;
• coping with clothing;
• use of sanitary protection;
• mobility to and from the toilet;
• use of public toilets.
131
ADAPTIVE TECHNIQUES
Considerations
Independence in toiletting is a priority for many clients as assistance
can be embarrassing and demeaning. For clients who are experiencing
minimal difficulty in toiletting the range of equipment available can
often overcome problems and regain independence. It is when a client
is having difficulty in getting to or transferring from the toilet that
problems become more complex to solve. In this situation the amount
of assistance available is of primary importance and will influence the
solution arrived at. The problems created by dependence in toiletting
can be immense especially for clients living alone as highlighted by
the following case.
A lady with severe rheumatoid disease was admitted to hospital and
underwent a below knee amputation due to vasculitis and impaired
circulation. She was unable to use a prosthesis as she had neither the
upper or lower limb function to do so and the weakness of her upper
limbs made transferring independently impossible. She was provided
with an electric wheelchair and regained some mobility. She lived
alone and a home assessment was carried out. All aspects of her care
could be covered apart from toiletting. Nurses called to get her up in
the morning, home helps and meals on wheels called during the day
and nurses called to put her to bed at night. This was at a time when
home helps were unable to provide assistance with personal care, and
this situation has now changed in this lady's locality.
The two remaining problems were: what happened from 1O.OOam-
7.00pm between visits from the nurse and also what happened during
the evening and night, in respect to using the toilet? One solution was
to provide an electric wheelchair with an integral commode, but this
presented problems with sacral pressure care, the client felt it totally
unacceptable, not only in terms of the necessary clothing adaptations
but also in terms of dignity and hygiene. She did not have the manual
dexterity to use a female urinal. The day time was eventually over-
come by a rota of carers from friends and the voluntary sector calling
throughout the day.
The evening still remained however. The client tried numerous
female urinals and positions and eventually a custom made device was
produced which she could use with a great deal of effort. Her daughter
also decided to travel every night to help toilet her before she went to
sleep. The discharge from hospital was very tenuous and the main
reason was trying to cope with a client's personal care needs with a
limited resource. The option which had been considered at one point
was residential care purely through a client's inability to toilet
independently.
132
COMMON FUNCTIONAL PROBLEMS
Transfers
If a client is mobile but is having difficulty getting on and off of the
toilet a raised toilet seat can provide the extra height needed to
reduce stress on joints. The height on the seat can vary from two
to six inches and the seats should be secured to avoid slipping when
in use. Front cutouts enable clients with limited arm movement to
cleanse themselves from the front instead of behind. A seat can be
obtained with either the front left or right side shaped to accom-
modate a client who has a fixed hip and is unable to flex it to 90°.
If the extra height is not enough to assist a client to stand, a self-lift
toilet seat can be used which provides a spring seat which, as with
self-lift chairs, is set according to the client's weight.
If stability is needed grab rails fitted beside the toilet will provide
more assistance. If the wall is not strong enough to fix rails to a
free-standing or preferably a floor fixed frame can provide an
armrest on either side of the client to assist with transfers. Frames
which combine a seat as well as armgrips can be used. These are
usually adjustable in height and can be either free-standing or floor
fixed. If the frame is free-standing the client must be taught to use
both arm-rests when transferring to avoid the frame tipping.
If a client has limited mobility and is using a wheelchair enough
space must be available to enable the chair to be positioned correctly
for the client to transfer or for carers to assist without being
cramped. It is possible for some clients to maintain their
independence with the use of an overhead tracking hoist in combina-
tion with a sling with a commode aperture.
Some clients are unable to transfer and are totally reliant upon
outside agencies for their assistance. In this situation an alternative
means of toiletting is needed as bladder and bowel function cannot
be totally dependent upon the visit of the care attendant. Several
options exist, probably the most desirable is the use of aU-shaped
cushion in the wheelchair which allows for a urinal to be inserted
and used while sitting in the wheelchair. The success of this method
is dependent upon the client's manual dexterity to position the urinal
and remove it, adapted clothing is also required to overcome
problems of pants and tights.
Wheelchairs which combine commodes are available but do have
some limitations. Some clients, understandably, find the use of
wheelchair commodes embarrassing as talking to a visitor while
seated on a commode which you have just used can be distressing.
The other problem which these pose is that of pressure. Although the
133
ADAPTIVE TECHNIQUES
seats are padded, areas of high pressure can be caused around the
rim of the aperture. In some situations however the use of a
wheelchair commode can be the difference between remaining at
home or needing residential or long-term hospital care.
Flushing toilets
Sometimes clients can experience difficulty in operating toilet flushes
and adaptations are needed to either bring chains within reach or
provide a different grip.
134
COMMON FUNCTIONAL PROBLEMS
Beds
• transfers;
• comfort;
• pressure relief.
135
ADAPTIVE TECHNIQUES
Considerations
If a client is experiencing difficulties in relation to any of the above
it is likely that they and their partners are experiencing regular sleep
disturbance. This can range from being woken once every so many
nights to being awoken several times each night. The level of fatigue
experienced from loss of sleep can have a profound effect on both
client and carer. The awareness, on the client's behalf, of disturbing
their partner's sleep can lead to the decision to sleep in separate beds
or different rooms.
This isolation can be even greater for the client who is unable to
cope with stairs and has to move a bed downstairs while their part-
ner sleeps upstairs. Isolation caused by lack of sleep can be
experienced when a client, who is not sleeping during the night,
sleeps for long periods through the day to catch up, thus sleeping
while the family is awake and being awake when the family is
asleep.
If a client is spending a lot of time in bed a special bed may be
needed to enable the client to adjust their position independently,
assist carers with transfers or care functions and provide pressure
relief. It is difficult to assist with many care functions in a double
bed which is not adjustable in position or height and where easy
access to both sides of the bed may not be possible.
Transfers The main problem of getting into bed is often raising legs
up onto the mattress and the problem with getting out is rising from
a low base. Small spiral steps called bedhoppers are available to
enable clients to work their legs up onto the bed in stages. The
height of beds can be increased by the use of blocks or raises.
However raising the height may assist with getting up but make
getting in more difficult.
136
CLOTHING
and try to slip an arm under the lumbar curve. If it slides through
easily the mattress is too firm, if the pelvis has to be arched to get
it through the mattress is too soft. The arm should slide through with
a small amount of movement required.
Bed paddings are an effective way of providing cushioning for
painful joints. They are placed on top of the mattress and are usually
made of fibre filling. They can be purchased with a plastic or
material covering. If this padding is to be used at home it may be
worth considering the use of a segmented mattress as these are more
easily laundered. The sections can be removed from the cover and
the cover washed like a sheet. Sheepskin fleeces also provide a
degree of comfort for painful joints.
Special pressure-relieving mattresses can be obtained for clients
who are at high risk of developing pressure sores. These can be air
filled, or floatation and provide a higher degree of pressure relief
than ordinary mattresses or fleeces.
CLOTIDNG
137
ADAPTNE TECHNIQUES
MOBILITY
Walking aids
The use of some walking aids can be made difficult by the grip
required to hold them, the strain placed upon joints while using them
or the strength needed to move them. Specially moulded handles are
available for sticks and crutches which distribute the pressure more
evenly over the whole hand.
138
MOBILITY
Manual wheelchairs
139
ADAPTIVE TECHNIQUES
Powered wheelchairs
140
MOBILITY
141
ADAPTIVE TECHNIQUES
powered chairs. They have the ability to travel similar distances and
to cope with kerbs and, like chairs, differ in their suitability for
different environments. They are also powered by batteries. Again
a sustained grip is needed to operate the scooter and there is a larger
degree of variability between models in the grip required. The size
of scooters can prohibit access to some buildings. Clients who have
some degree of mobility use scooters to travel long distances to and
from shops being able to walk around the shop once they arrive.
Scooters are perceived as being more socially acceptable than
wheelchairs and also have the bonus of being less expensive.
The other form of powered mobility available are buggy type
vehicles. These vehicles are large and purely for outdoor use requir-
ing garaging and access to power to recharge batteries. These
vehicles do give a much greater degree of weather protection and
again are more suitable for clients who have a degree of mobility as
access to buildings is a major problem.
Clients buying some form of powered vehicle should be
encouraged to take out an insurance policy including third party
cover, as it is possible that they could be involved in an accident.
Car adaptations
142
MOBILITY
providing all round visibility. Access to and from the car can be
difficult for clients with severely limited movement, especially if
they require assistance with transfers. Existing car seats can be
replaced by swivel car seats which rotate round out of the car to
enable a client to do a side transfer from a wheelchair or for carers
to assist more easily with transfer. Once the client has transferred
onto the seat it is rotated back around into the car. Limitation in
upper limb movement may also present difficulties in relation to
using a seat belt. Adaptations can be made to belts to bring them
into the reach of a person with limited shoulder movement.
One of the problems experienced by non-drivers is identifying
driving instructors who have adapted cars on which to learn. Local
instructors with limited adaptations are usually identifiable. Clients
with a greater degree of disability may require a specific assessment
of their limitations and abilities to establish exactly what adaptations
are required to assist them to drive and these are carried out at
assessment centres such as Banstead Place Mobility Centre.
Home management
143
ADAPTIVE TECHNIQUES
Opening cans
For many clients electric can-openers are the most effective way of
opening cans, requiring little grip or hand strength. Many have a
lever action and if the lever is large then the heel of the hand or the
forearm can be used to operate.
Plugs
Pulling electric plugs in and out of the socket or reaching the socket
can cause problems. Plugs can be purchased with large handles on
them to enable the whole hand to be used, rather than just the finger
tips. Extension brackets can be plugged into sockets near the floor
and wall mounted to bring the socket within the reach of clients with
restricted movement.
Taps
Lever action taps are easier to use as they place less stress on the
fingers. Tap turners can be used to adapt existing taps if replacement
is too costly, they can be fitted to ordinary or crystal taps. If clients
are replacing taps with lever mechanisms, ones which have 180 0
turn provide more control over the volume of water coming out of
the tap than the 90 0 mechanism.
Saucepans
Problems related to lifting saucepans can be overcome by placing
vegetables etc. in cooking baskets, so that when they are cooked
they can be lifted from the pan negating the need to carry pan and
water and also to drain them. The use of microwaves can reduce
significantly the amount of lifting of heavy hot utensils in the
kitchen.
Kettles
Filling can be made easier by using a plastic jug, rather than carry-
ing a heavy full kettle. Problems associated with lifting and pouring
can be overcome by, using a kettle tipper, tippers are now available
for jug as well as conventional kettles using a smaller travelling
kettle or a microwave to make drinks in. Small drinks dispensers are
also available from large department stores.
144
MOBILITY
Utensils
The handles of utensils can be padded for clients with restricted grip,
or ranges of knives are available with the handles in different posi-
tions placing less strain on the wrist when in use. The grip of uten-
sils should be considered when buying equipment as often
conventional ranges can offer a better grip, rather than having to buy
specific equipment designed for people with disabilities.
145
ADAPTIVE TECHNIQUES
and high street shops selling equipment widens the potential for
errors to be made, however many of the new retail outlets either
employ therapists or use therapists to train staff and are aware of the
potential to not only waste a client's money but also in some cases
cause harm.
Assessment should ensure that appropriate equipment is provided
and kept to a minimum. A factor which is often neglected due to
lack of therapist time is that needs change and equipment may either
no longer be needed or may need reassessing. This is often left to
the client to report and the assumption made that if the client has not
been in contact the equipment must be alright. While a routine
reassessment is out of the question therapists should ensure that
clients know who to contact if their needs change or if the equipment
breaks down.
FURTHER READING
146
7
Housing adaptation
147
HOUSING ADAPTATION
148
HOUSING ADAPTATION
(a) (i) any needs of the disabled person which in the opinion of the
authority call for the provision by them of any statutory
services and;
(ii) in the case of each such need, the statutory services that
they propose to provide to meet the need;
or stating that, in their opinion, the disabled person has no
needs calling for the provision by them of any such services
and;
(b) giving an explanation of their decision'
While not all of the sections of this act have as yet been
implemented it will provide clients with a procedure of appeal and
representation and make local authorities and therapists more
accountable for their decisions and actions. This act also states that
in all assessments for the provision of services to disabled people the
needs of carers must also be taken into account. This section will
now go on to look at specific adaptations which may be needed for
a client with rheumatoid disease.
149
HOUSING ADAPTATION
Reach
The ability to reach into wall cupboards and lift something down
may be limited as may the ability to reach across work surfaces by
decreased range of movement in the upper limbs, or decreased
strength. If a person is in a wheelchair their ability to reach will be
compromised not only by possible upper limb involvement but also
by the fact that they are functioning from a seated position.
Ability to bend
Poor balance and limited hip movement may make bending down to
cupboards, plug sockets, or the bottom of the fridge, cooker or other
appliance difficult. Knee movement and pain may mean that clients
can no longer kneel on the floor. This will also be the case if a
client has undergone a total knee arthroplasty.
150
KITCHEN DESIGN AND ADAPTATION
Stamina
Levels of fatigue may make standing for any period of time difficult
and many kitchen activities may need to be carried out sitting down.
Muscle weakness may make standing for prolonged periods difficult.
Hand function
This may limit the client's ability to use controls, switches plugs,
taps, open cupboards, etc.
Mobility
If the client is using an aid to mobility this may affect the amount
of circulation space needed in the kitchen.
Other factors which need to be considered are how much the client
is intending to use the kitchen and what for. The level of use will
range from needing to make a drink or a snack to needing to prepare
all the family meals and carry out other domestic activities such as
laundry. The possible longterm prognosis of rheumatoid disease is
also a consideration. If the kitchen is being planned for an ambulant
person it may be worth using a kitchen unit which allows for easy
repositioning of height should the client at some point need to use
a wheelchair. The flexibility of units heights is an important factor
if considering a kitchen which will be used by different occupants
as in local authority housing schemes. Repositioning enables the
same kitchen to be used whether the client is ambulant or uses a
wheelchair. Although the initial cost may be more the flexibility
negates the need to refurbish the kitchen to meet the needs of a new
tenant.
The use to which the kitchen is put is also another factor to
consider. For many people the kitchen fulfils a much greater role
than that of a food preparation area. It may also be a dining area,
or the focal point of the home in which friends are entertained,
children play and television is watched. Many kitchens also provide
access to the garden, utility room or garage; all of these factors can
influence ultimate design.
In a family situation usually more than one person uses the kitchen
area and the needs of other family members are important. In some
situations decisions have to be taken as to who the kitchen is being
151
HOUSING ADAPTATION
152
KITCHEN DESIGN AND ADAPTATION
153
HOUSING ADAPTATION
Appliances
Overall position
Appliances should be positioned to minimize the amount of move-
ment between them. Thought should be given to the proximity of
work surfaces to minimize the distance items have to be carried.
Specific surfaces may be located in close proximity to appliances like
ovens. A pull-out work surface is often located under the oven in an
oven-casing to provide a surface to rest hot dishes on.
Access to appliance
The height at which appliances are situated can determine how
accessible they are. Placing fridges in built in units allows them to
be situated above floor level giving easy access to all shelves. A split
level cooker provides easy access to ovens, many clients find
bending to lift dishes from the oven very difficult and dangerous.
Upright deep freezes provide easier access to the contents than the
chest type, as less bending and reach is required to use them.
Ease o/use
The type of controls on appliances are an important consideration
when purchasing as is the ease of cleaning.
154
BATHROOM ADAPTATION
BATHROOM ADAYfATION
1. mobility
- access to the bathroom during the day can be difficult if it is
located upstairs;
- Clients using aids to mobility may find their bathroom too
small to manoeuvre the aid around in;
2. inability/difficulty to transfer due to pain, stiffness or loss of
movement;
3. 'problems with cleansing after using the toilet.
Mobility
Access to and around the bathroom can pose problems. The provi-
sion of a stairlift is a common way of gaining access to the
bathroom, if upstairs, during the day. However in some homes the
stairs may not be suitable for the installation of a lift and the provi-
sion of a downstairs bathroom and bedroom may be considered.
The use of walking frames and wheelchairs in bathrooms can be
155
HOUSING ADAPTATION
inhibited by the size of some rooms, especially if the bath and toilet
are in separate rooms. It is necessary sometimes to remove dividing
walls to gain a greater circulation space, if the problem cannot be
overcome by the provision of more compact aids to mobility, and
to provide adequate space for transfer to be carried out safely.
Transfers
Bathing
The provision of assistive equipment to assist with transfers in the
bath has already been discussed, for some clients however the
provision of a shower may be preferable. Even with assistive equip-
ment clients may need assistance to swing their legs up over the
side of the bath and still be dependent upon assistance from a carer.
Many bath aids have rigid backs preventing the upper body from
being immersed in the warm water. Some clients prefer the overall
warmth provided by a shower as they feel it relieves pain and
stiffness.
A large variety of shower trays exist which provide level access
to the shower, either to walk in to or to use in combination with
a mobile shower chair. The main consideration in relation to the
size of the tray is whether the client is ambulant or a wheelchair
user. The type of shower installed varies considerably from a non-
slip tiled floor with a central drain to a shower cubicle depending
on the constraints of the client's bathroom and the policy of the
local authority. Some of the showers have a full length curtain,
some have half doors and some a combination of both. It is essen-
tial that the shower unit is thermostatically controlled and conforms
with British Safety Standards to ensure that clients cannot be
scalded if there is a variation in water temperature. The temperature
of some showers varies if a person downstairs turns on the cold
water tap decreasing the pressure and increasing the heat of the
water, clients with limited mobility will not be able to move out of
the way quickly. The controls on the shower should be operated
easily, a wide range of controls are now available including
pushbutton and knobs.
The position from which the client is to shower is also a
consideration as, if it is seated, the type of seating provided may
influence the choice of cubicle. Shower seats can be:
156
BATHROOM ADAPTATION
Therapists must determine the most appropriate type for their client,
bearing in mind possible weight restrictions of wall-mounted seats
and the construction of the wall to which it is to be fixed.
If a client is living in local authority or privately rented acco-
mmodation it may not be appropriate to remove the bath perma-
nently. Shower trays are now manufactured to the same dimensions
as the bath, provided a showering area and a changing area, and
using the same drainage system. When a new tenant moves into the
house it is possible to reinstate the bath if required with very little
upheaval.
In some situations it may be appropriate to provide an alternative
bathroom downstairs and an extension may have to be built. If
space is restricted a bathroom cubicle exists which provides a toilet
and shower facility within one cubicle requiring very little space.
Location will depend upon drainage and situation in relation to the
kitchen but for some clients provides a solution to having to move
home. A recent addition to the market has been the production of
a prefabricated bathroom which can be adjoined to a building. The
only preparation needed is the drainage, a concrete base to stand it
on and access to the house. The internal design can vary to meet
the needs of the individual.
Overhead tracking hoists assist clients with transfers not only into
the bath but also on and off of the toilet. They are ceiling fixed and
run along either a straight or curved track, used in combination
with a sling. In some situations they are installed to assist the carer
while in others for the client to use independently. If the client has
the upper limb movement to attach the sling to the hoist they can
transfer themselves. Slings can be adapted, if necessary to maximize
the upper limb function a client has.
Toiletting
The inability to cleanse after using the toilet can be an embarrassing
problem for both the client and their carer. The provision of a bidet
can overcome this problem and restore dignity and independence for
clients. Some bidets have a variety of methods of operation, the most
common type used being electrical, and also offer the option of
157
HOUSING ADAPTATION
having a warm air drying facility to enable clients to cleanse and dry
themselves independently. If a client is dependent upon a carer for
toiletting a bidet can greatly assist the carer, as trying to stand
someone up, clean them and cope with clothing is extremely
difficult.
Mobility problems
Access to the house Access to the house can be a problem not only
in terms of the client getting in and out but also in relation to letting
visitors in and out. The solution to access problems will inevitably
depend upon:
If steps are too high for clients to climb doubling the amount of
steps halves the height of the step to be taken, this for some clients
enables them to gain access more easily. Often the support of rails
when climbing s\~ps is beneficial. If a client uses a wheelchair or
walking frame the provision of a ramp may be indicated. The recom-
mended gradient for a ramp is 1:20, but this is not always possible,
the maximum gradient should be 1: 12. If the client's steps lead
directly onto a public footpath a permanent ramp cannot be provided
as it would obstruct the public highway, in this situation a portable
ramp may be more applicable if someone is available to lay it down
and remove it after use. The surface of the ramp should be non-slip
and a level landing should be provided at the entrance of the house
to enable the client to open the door without rolling backwards.
158
BATHROOM ADAPTATION
Stairs
An adaptation required frequently for clients with rheumatoid
disease is the provision of a stair lift to gain access to the upstairs
of a house. It is more cost effective than providing a bedroom and
bathroom downstairs and is not a permanent feature of the home.
Stairlifts are basically designed with a straight or curved tracking
which fits onto the staircase and has a seat which either travels up
the stair sideways or backwards. They also provide a footplate. The
height of the seat is crucial for many clients, especially in relation
to the foot rest as this dictates how much knee flexion is required
to sit on the seat and in relation to overall height for transfers on
and off of the seat. Stairlifts can also be provided with a standing
platform if clients are unable to transfer from a seated position.
Some of the seats swivel around so that when the client is getting
off at the top of the stairs they can have their back to the staircase
and transfer in safety.
The lifts are controlled by a pushbutton switch requiring constant
pressure, although alternatives are available for clients with limited
hand function, some companies provide rocker switches or joy stick
controls.
Throughfloor lifts are provided either where the staircase is
unsuitable for the installation of a stairlift or where the client is
unable to transfer onto the seat of a stairlift. They are usually
situated to travel up into a bedroom. The lift is usually kept upstairs
until needed so that it forms part of the ceiling and is brought down
into the room when required, enabling the client to walk or wheel
in.
This section has covered some of the adaptations that are carried
out for clients with rheumatoid disease. Assessment is essential to
identify the individual needs of clients and their families and to
determine environmental factors which may influence recommenda-
tions. Once this has been carried out therapists are then required to
159
HOUSING ADAPTATION
identify how these needs can be met within the policy of the
particular authority for whom they work. This is often a process of
compromise between what is desirable and what is acceptable.
Clients must be fully involved in this process to gain an understand-
ing of the processes being gone through and the meaning of this for
both themselves, their family and their home.
More clients are now considering paying for adaptations privately,
usually due to long waiting lists for assessment or a dissatisfaction
with recommendations. The one problem that is encountered by
clients, however, is the availability of advice. While some clients
may have access to Disabled Living Centres the availability of
therapists who can carry out a home visit, which is essential, is
limited. Clients in many areas have an all or nothing service
whereby the community occupational therapist will assess if an
application is made to social services but not if the client wishes to
fund the adaptation for themselves. This consultancy service is an
area of need which has not been met as yet by the profession and
should be addressed.
With the emphasis of healthcare being shifted into the community
the need for the provision of both appropriate housing and housing
adaptation is essential to ensure that the underlying philosophies of
community care become a reality. The environmental barriers
provided by a home can be immense resulting in isolation and a
dependence upon other people for tasks which, given the right
environment, could be carried out independently. The stresses placed
upon the family as a whole can develop into a crisis if unrecognized.
Clients with rheumatic diseases are not always given high priority on
waiting lists as they do not have a life threatening illness nor are
they recovering from an acute traumatic event. The problems
encountered by clients often fall into low priority categories and can
be left for some considerable time before being addressed.
Community care is now a reality and the needs of clients with
rheumatoid disease are very much community orientated. The
debilitating effect of living in accommodation which is not suitable
and does not enable basic needs to be met as independently as possi-
ble is substantial, not only on the client but on the whole family unit.
Much valuable time and energy can be spent in fulfilling basic needs
often leaving clients too tired or in too much pain to consider
embarking upon less essential activities. A home which fulfils basic
needs is essential to anyone and should be a priority if the potential
of community care and integration is to be met, both from the point
of view of the client and the whole family unit.
160
FURTHER READING
FURTHER READING
161
8
Splinting
Classification of splints
162
SPLINTING
static splint prevents movement and rests the affected joints. As its
primary aim is to immobilize, it should be used as a component of
a therapeutic programme to ensure that atrophy, weakness and stiff-
ness do not occur as a result of wearing the splint. If the splint is
to be used at home therapists must ensure that the client is aware
of the need to exercise an immobilized joint as and when
appropriate.
Dynamic splints allow movement and so are constructed to incor-
porate hinges, elastic or springs or utilize the movement of another
body part.
Classification according to the function of the splint falls into three
categories:
1. resting;
2. functional;
3. corrective.
163
SPLINTING
Hand assessment
164
SPLINTING
1. Grip strength:
- power grip;
- pinch grip;
- cylindrical grip;
- hook grip.
2. Sensation
3. Function; examples of functional components of assessment
include:
- pouring water from a jug to a glass;
- writing name;
- picking up small objects and placing in a container;
- buttoning and unbuttoning a garment;
- tying a shoelace;
- opening and closing a zip;
- moving different size and shaped objects from one position
to another.
Fabrication of splints
165
SPLINTING
166
SPLINTING
6. cost of material;
7. skills of the therapist;
8. condition of the client's skin, allergies, open wounds, etc.
167
SPLINTING
Resting splint
This splint is designed to extend from the mid forearm to the tips
of the fingers, supporting the palmar aspect of the hand. It is used
to maintain the hand in a functional position providing rest to the
joints and decreasing inflammation.
The splints are fabricated with varying degrees of wrist extension
which should not exceed 30 0 , and should be within a painfree range.
If a client has carpal tunnel syndrome the wrist should be maintained
in a neutral position. The fingers are slightly flexed. An ulnar ridge
may be needed if clients have ulnar deviation to maintain the fingers
in the correct alignment. The thumb is opposed and abducted.
168
FURTHER READING
Corrective splints
FURTHER READING
169
9
Relaxation and pain control
170
RELAXATION AND PAIN CONTROL
171
RELAXATION AND PAIN CONTROL
1. Does the patient actually feel less pain or have they simply learnt
to complain less?
2. How do the programmes compare to the placebo effect? Such
programmes usually necessitate constant attention and hospital
admission.
3. Such programmes are expensive to implement and run and if the
programmes are effective will they be available to everyone?
(Melzack, 1982)
172
RELAXATION AND PAIN CONTROL
The way in which rest and joint protection can be used to reduce
pain have already been discussed but an area not previously covered
is the use of relaxation techniques. Most techniques require very little
equipment, other than a quiet room with comfortable chairs or floor
mats, and can be used easily at home. They aim to reduce muscle
tension, lower the heart rate, respiratory rate and blood pressure and
help clients cope with stress which is present when coping with
rheumatoid disease. Before embarking upon relaxation sessions it is
essential that clients understand the rationale behind the use of the
technique and the expected outcome. Emphasis should also be placed
upon the fact that relaxation is a skill which can be learnt and that
it may take several sessions for a relaxed state to be achieved.
Relaxation sessions should be carried out in an environment which
is free' from distraction (something which can be difficult in a busy
hospital setting) warm and comfortable. Some clients will be unable
to lie on the floor and will be more comfortable sitting in a chair
but it should provide good head and arm support and be the correct
height. The use of foot stools may provide more comfort.
The most common types of relaxation used in a clinical setting
are:
Guided imagery
173
RELAXATION AND PAIN CONTROL
Controlled breathing
Biofeedback
174
RELAXATION AND PAIN CONTROL
Yoga
175
RELAXATION AND PAIN CONTROL
to deal with pain but also the stress, anxiety and tension that can
result from living with rheumatoid disease.
FURTHER READING
176
10
Personal and sexual relationships
Communication
177
PERSONAL AND SEXUAL RELATIONSHIPS
178
PERSONAL AND SEXUAL RELATIONSHIPS
179
PERSONAL AND SEXUAL RELATIONSHIPS
Practical advice
180
PERSONAL AND SEXUAL RELATIONSHIPS
Contraception
181
PERSONAL AND SEXUAL RELATIONSHIPS
182
FURTHER READING
FURTHER READING
183
11
Community care
184
COMMUNITY CARE
185
COMMUNITY CARE
186
COMMUNITY CARE
1. personal assistance;
2. household management;
3. special housing;
4. aids and equipment;
5. day care;
6. respite for carers;
7. counselling and advice (Beardshaw, 1988).
187
COMMUNITY CARE
Choice
188
COMMUNITY CARE
Consultation
Information
Participation
Recognition
That long-term disability is not synonymous with illness and that the
medical model of care is inappropriate in the majority of cases.
Autonomy
That is, freedom to make decisions regarding the way of life best
suited to an individual disabled person's circumstances (Fielder,
1988).
These guidelines should be fundamental to the planning and execu-
tion of any service related to people with rheumatoid disease and an
honest examination of both personal practice and the functioning of
189
COMMUNITY CARE
190
FURTHER READING
FURTHER READING
V. Beardshaw (1988) Last on the List, Community Services for People with
Physical Disabilities, Kings Fund Institute, London.
M. Bulmar (1987) The Social Basis of Community Care, Unwin Hyman.
B. Fiedler Living Options Lottery, Housing and Support Services for People
with Severe Physical Disabilities, 186/88, The Prince of Wales Advisory
Group on Disability.
c. Hicks (1988) Who Cares? Looking After People at Home, Virago Press,
London.
191
References
192
REFERENCES
193
REFERENCES
194
Index
195
INDEX
196
INDEX
197
INDEX
198
INDEX
199
INDEX
200
INDEX
201