♦ Progressive dependence in ADLs is one of the primary problems reported to the OT by the PD patient, the patient's family, and the carer.

♦ The dependence grows as the motor symptoms progress, as rotational movements decrease, and as flexibility declines.

♦ The speed of performance of self-care activities may also be affected. There may be difficulty performing two motor tasks at one time, delayed initiation, slow execution, and difficulty sequencing within a task, or sequencing several tasks.

♦ Treatment includes:

O The development of an ADL routine that reflects the state of the mobility of the patient at the time of the task. O Multisensory feedback, including verbal cueing, is used to facilitate performance as the patient practises the functional movement. O Instruction is given regarding choosing adaptive and assistive devices (117).

♦ The primary focus is practice of the tasks. Accommodation techniques are stressed.

♦ The patient and the carer are also instructed regarding environmental adaptations for ADL success both in the set-up and in the use of adaptive or assistive devices. These are used when the patient is unable to perform the activity without the device, when the device significantly decreases the time required to perform the activity, and/or the device allows the patient to perform the task while in a safer position.

♦ Energy conservation strategies are incorporated into the individual tasks in the treatment regimen.

♦ All of these considerations are addressed in the following areas:

117 Assistive devices for ADLs.These devices help the patient in retaining independence in self-care and/or increasing safety during performance of self-care tasks. Illustrated from the top to bottom are the following - reacher buttonhook, sock-aid, Good Grips® rocker knife, long shoehorn, Good Grips® fork, and long-handled bath sponge.

O Bed mobility. Tricks of movement are taught, and provision of a ladder strap or a bed rail may be considered.

O Mobility throughout the home. Environmental adaptations such as rearranging the furniture, removal of throw rugs, reducing clutter or other pathway distractions, and provision of even lighting may be discussed. Suggestions for remote controls to the television, or hand-held phones may be used to prevent rushing, therefore decreasing falls.

O Showering. Use of soap on a rope, terry cloth robes for drying, and shower benches may be recommended.

O Toileting. Raised toilet seats and grab bars may facilitate independence and ensure a greater level of safety in the bathroom.

O Grooming. Electric shavers may increase safety for men and women. Stabilization of the upper extremities on the edge of the sink may increase the stability of the arms for tasks at the head and neck level.

O Dressing. Adaptive methods are taught in an effort to maximize the patient's successful movement patterns. Instruction is given regarding choosing loose clothing with easy fasteners to minimize the need for fine motor control.

O Feeding. Larged-handled or security grip handled utensils may be suggested. Emphasis is on preparation of small portions, more frequent meals, and longer meal times to prevent rushing.

O Meal preparation. Adaptive jar openers, rocker knives, or dycem non-skid pads are often recommended. Sitting for aspects of meal preparation may be suggested. O Household chores. Lightweight vacuum cleaners and dust mops may increase success and help to manage fatigue. Long-handled scrub brushes may facilitate independence with tasks when the patient is unable to bend or reach overhead. Handwriting is included in the ADL arena, and often is the primary reason for referral of PD patients to an OT. Difficulties can include a lack of legibility due to tremor, or problems with micrographia. Treatment of handwriting problems includes:

O Exercises to increase in-hand manipulation skills (118). O Eye/hand coordination drills. O Provision of proximal stability. O Graded individual finger movements. O Alternative methods with use of a computer. O Fabrication of a writing splint (119). O Callirobics Writing Program.

While the mean age of onset of PD is around 60 years, some PD patients are diagnosed before the age of 40. Therefore, consideration of work duties must be addressed. Treatment includes: O Instruction regarding work hours and schedule modification. O Variance of work tasks. O Ergonomic work site assessment.

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