ADL Training

DESCRIPTION OF INTERVENTION

Hand therapists help patients regain skills needed to complete routine activities of daily living (ADL). See “core ADLs below. In addition, they work with patients to facilitate ability to perform activities that—while not completely essential—give meaning to a person’s life or instrumental activities of daily living (IADL).  IADLS support daily life and are oriented toward interacting with the patient’s environment. Typically, more complex than ADLs, IADLs are important components of home and community life but can be delegated to another person.¹ ADL training can be helpful for anyone experiencing impaired daily functioning caused by any pathology, condition, injury or other impairment that affects hand function.

Core ADLs include¹:

• Bathing/showering
• Toileting and toilet hygiene
• Dressing
• Eating/swallowing
• Feeding (the setting up, arranging and bringing food to the mouth)
• Functional mobility (the ability to get from place to place while performing ADLs, either under one’s own power or with the assistance of a wheelchair or other assistive device)
• Personal device care (utilizing essential personal care items such as hearing aids, contact lenses, glasses, orthotics, walker, etc)
• Personal hygiene and grooming
• Sexual activities
• Instrumental ADLS may include:
• Care of others 
• Care of pets
• Child rearing
• Communication management
• Driving and community mobility
• Financial management
• Health management and maintenance
• Home establishment and management
• Meal preparation and clean up
• Religious and spiritual activities and expressions
• Safety procedure and emergency responses
• Shopping
• Rest and sleep
• Education
• Work 
• Play 
• Leisure
• Social participation

INDICATIONS FOR INTERVENTION

Patients may have short-term needs for help with ADLs during periods of protection or immobilization after surgery or injury.  Short-term needs still often require special one-handed techniques and low-cost modifications to simplify life and increase independence.² Patients with long-term but still not permanent decrease or loss of the ability to use a hand, may require yet other solutions to optimize ability to achieve task accomplishment. Yet other patients may permanently lose an entire hand or the full or partial function of one hand.³  The patient who loses both hands or arms, requires an even more involved set of interventions and solutions to make accomplishment of daily tasks possible.

The patient who loses the use of a dominant hand may require dominance transfer training to acquire the ability to write and other tasks that the dominant hand previously performed.⁴

EVALUATION TO DETERMINE NEED FOR INTERVENTION

The therapist must first identify ADL challenges with their patients and then work with the patient to prioritize and focus. Cultural sensitivity will contribute to successful intervention. Clinicians must consistently assess or interview their limb-affected patients to determine if they are struggling with or unable to perform important ADL or IADL activities.  Ideally, the therapists specifically evaluate ADL/IADL performance during either the initial evaluation or soon thereafter to determine the activities that the patient finds challenging and which ones they prioritize.

Literally hundreds of ADL assessments exist.⁵ Evaluation consists of both questionnaire and functional tests. Functional tests offer the clinician to observe the patient performing activities and often have norms associated with them. These include but are not limited to:

• Jebson Taylor Hand Function Test⁶
• Sollerman Hand Function Test⁷
• Rosenbush Test of Finger Dexterity⁸
• Corbett Targeted Coin Test⁹
• Purdue Pegboard
• Bennett Hand Tool Dexterity Test¹⁰
• Crawford Hand Tool Dexterity Test
• Minnesota Rate of Manipulation Text
• 9 Hole Peg Test

Therapists will frequently associate certain ADL task difficulties with specific diagnoses.  As an example, a patient with CMC OA will have difficulty and pain with turning a key in a lock and opening containers. Therapists specializing in hand/arm amputation will know that bi-manual tasks such as shoelace tying and typing will require retraining with modified techniques. However, a full evaluation will always have value to identify the multiple task challenges that each patient encounters.

INTERVENTION OPTIONS

An important rehabilitation goal is independence in ADL and IADL. While some ADL challenges are highly predictable given a specific situation or disease, they are often unique to a given patient. As part of a comprehensive plan of care, hand therapy focuses on self-care activities and improvement of fine motor coordination of upper extremity muscles and joint. As a cornerstone of independent living, the therapist can use ADLs as treatment.  ADLs involve tasks that use motor memory automaticity as well as high levels of motivation.¹¹ Achieving ADL solutions often involves a high level of information synthesis and creativity. The therapist, patient and sometimes a caregiver can practice skills with the patient to accomplish an ADL goal.

ADL training or retraining consists of occupation-based activities and simulation of activities to work on specific skills.  It can involve introduction to adaptive equipment or strategies to overcome barriers to task performance. Clinicians may collaborate together to problem solve for the most effective solutions.

This training can include exploration of prosthetics and training with the chosen device.³ It can also involve learning to perform dominant hand activities with the non-dominant hand. This latter intervention, called dominance retraining or dominance transfer, involves activities graded from gross to fine.⁴

Patients should attempt to master one-handed ADLs when they lack either the use of their involved hand or a prosthesis.  Therapists train patients to perform one-handed ADLs using ergonomic principles to prevent cumulative trauma disorders. To optimize independence in different environments, the clinician will minimize the use of adaptive equipment and focus instead on adaptive techniques.³

However, the following adaptive aids can be helpful. Many of these products are commercially available.³

• One-handed nail clipper and nail brush
• Sensor soap dispenser
• Hands-free wall-mounted shower dispenser
• Body scrubber
• Wash mitt
• Button hook
• Disposable dental floss holders
• Hair dryer stand
• Elastic shoelaces
• Rocker knife
• Pizza cutter
• One-handed cutting board
• Zim® jar opener
• Chopper/food processor
• Hands-free can opener
• Dycem® (non-skid mat)
• Keyless entry

List of common activities to practice:

• Cut food
• Tie shoelaces
• Open a tube of toothpaste
• Use scissors to cut paper
• Zip jacket
• Don socks
• Buckle a belt
• Stir (in a bowl)
• Use a fork and knife
• Fold towels, clothes
• Butter bread
• Hammer and nail
• Screwdriver and screw
• Open and close various types of packages, cans, boxes, and jars
• Peel and cut vegetables
• Peel hard boiled egg
• Crack egg
• Hang clothes on hanger
• Pull tape off dispenser
• Open 3-ring binder
• Punch holes in paper
• Apply band-aid
• Tie necktie
• Carry serving tray
• Draw lines with ruler
• Open pop-can
• Open water bottle
• Put pillow in pillowcase
• Money in/out of wallet
• Shuffle cards

Precautions for this intervention include:

• Using cultural sensitivity to choose appropriate ADL tasks
• Awareness of neurologic and cognitive issues which may affect the patient’s ability to learn and perform activity modification
• Gradual introduction of ideas for activity independence to prevent overwhelming the patient

Associated Diagnoses Where This Intervention May be Relevant

• The therapist will usually incorporate ADL training as a part of joint protection training for people with rheumatic diseases.
• The need for some ADL training will likely exist with most diagnoses that limit the use of one or both hands