Pre-Clinical Training Workshop

• Revisit selected info. & skills that commonly required for cl

inical training esp. among hospital settings under Hospital
Authority, i.e. CMC, KWH, POH, &, TPH

• Include three topics (@ one hour & fifteen min)

– Clinical conditions, including practice of: i) clinical tests for signs &
symptoms of certain disease, &, ii) retrieving medical history from
a “Discharge Summary”
– Awareness of Complications & Safety Precautions, including practi
ce of: i) transferring a patient (including rising from bed), &, facilitat
ing walking with common walking aids
– OT Processes including practice of a quick approaching for asses
sing AROM, MMT, etc.
 Pre-Clinical Training Workshop

Part 1. Revisiting Clinical Cond

itions Commonly Seen
(including common clinical tests)
Prepared by
NG Bobby, DR.
PDOT, DipEpiBiostats, MPH, PhD
Adjunct Assistant Professor, Tung Wah College - BSc(Hon) in
Occupational Therapy (2014 - )
Ex-DMOT, Kowloon Hospital / OTI Yang Memorial Social Service
 Conditions Covered
• Neurological Conditions
– Stroke1, chronic subdural hematoma2, Parkinson’s disease3

• Cardiac Conditions
– Valvular disorders4, Acute Coronary Syndromes5, Congestive Hear
t Failure6

• Pulmonary (Respiratory / Chest) Conditions

– COPD (including AECOPD)7, Respiratory Failure8, Pneuomonia (in
cluding related complication, e.g. Sepsis)9

• Ortho-geriatrics Conditions
– Colle’s Fracture10, Hip Fractures11, Cervical Spondylotic myelopath
12
 I. Neurological Conditions
(esp. Stroke, Chronic Subdural Haemato
ma, Parkinson’s Disease)
1. Stroke
 thrombotic

Ischemic Hemorrhagic

embolic A hemorrhagic stroke

occurs when a blood
An ischemic stroke occurs vessel bursts within
when a blood clot blocks the brain
the blood flow in an artery
within the brain

Ischemic Stroke Syndromes

(Bamford’s or Oxfordshire
1. Intracerebral
Community Stroke Project
hemorrhage
Classification),
2. Subarachnoid
hemorrhage
1. Total Anterior Circulation
infarcts (TACI)
Higher
2. Partial Anterior
Circulation infarcts (PACI) mortality rate
3. Posterior circulation
infarcts (POCI)
4. Lacunar infarcts (LACI) Hemorrhagic stroke
may have,
• headache / neck pain
Other Classification • vomiting / nausea
1. Grey matter lesion --
Cortical stroke / large
artery disease (LAD)
2. White matter lesion --
Subcortical stroke / small
vessel disease (SVD) /
lacunar infarct
 Ischemic Stroke Syndromes based on Involved Circulation

Anterior Circulation Stroke Posterior Circulation Stroke Lacunar Stroke

Combination of: i) new higher cerebral dysfunction (.e.g. dysphasia, visuospatial disorder); ii) homonymous visual field deficit,
&, iii) ipsilateral motor and/or sensory deficit of at least two areas of the face, arm, and leg
Total Anterior Circulation infarcts (TACI) = Present of all THREE symptoms
Partial Anterior Circulation infarcts (PACI) = Present of any TWO of the three symptoms
 Stroke Symptoms
1a. LOC

1b. LOC: Questions

(as illustrated by NIH Stroke Scale)

1c. LOC: Command

7. Limb
Ataxia

2. Gaze 8. Sensory

3. Visual 9. Best
(fields) Language

4. Facial
Palsy

5. Motor 10.
Arm Dysarthria

11.
(Left & Right)
Extinction
and
Inattention

6. Motor
Leg

(Left & Right)

The Neurological Examination & NIHSS
Neurological Examination NIHSS
 LOC  LOC
 Mental status and cognitive fu  Best gaze
nction  Visual field testing
 Cranial nerves  Facial paresis
 Motor system  Arm & leg motor function
 Sensory function  Limb ataxia
 Cerebellar system (coordinatio Sensory
n and gait)  Best language
 Reflexes
 Dysarthria
 Extinction & inattention
 Symptoms illustrating Brain Stem (i.e.
Midbrain, Pons, & Medulla – where cranial
nerves are housed) are involved

Trigeminal nerve Eye muscles

• Facial muscles (sensory)

Facial nerve
• Facial
muscles
(motor)

Tongue, pharynx & viscera

• That’s why having “2D”
 Dysarthria & Dysphagia
(bulbar palsy)
 for
Test
Item 2 of NIHSS: Gaze Testing Gaze
lem
Prob
 Tracking: establishing eye contact and moving about the
patient from side to side and observing if the patient’s e
yes follow
 The oculocephalic reflex (doll’s eyes) assessed by briskly
rotating the patient’s head side to side.
 Note:
 Normal response: eyes move in the opposite direction to head m
ovement
 Abnormal response: the eyes are fixed in one position and follow
the direction of passive rotation
Scoring: Best Gaze (0-2)
 0 = Normal horizontal eye movements
 1 = Partial gaze palsy – abnormality in one or bo
th eyes, but forced deviation is not present
 2 = Forced deviation, or total gaze paresis (not
overcome with oculocephalic maneuver)
 for
Test eld
Item 3 of NIHSS: Visual Fields Vis ua l
i
Fi
cits
D e f

 Stand 2 feet from patient at eye level. Both examiner an

d patient cover one eye. Ask patient to look directly into
your eyes.
 Test upper and lower visual fields by confrontation (4 qu
adrants of each eye).
 Examiner compares this to the “norm” (their own vision)
 To test both fields with eyes open, ask pt to indicate wh
ere they see movement (choices: L side, R side or both)
Scoring: Visual (0-3)
 0 = No visual loss
 1 = Partial hemianopia (sector or quadrantanopia)
 2 = Complete hemianopia
 3 = Bilateral hemianopia (blind)
 Note:
 If patient sees moving fingers, this can be scored as normal
 If there is unilateral blindness or enucleation, score visual fields i
n the other eye
 If there is extinction during double simultaneous stimulation scor
e a 1 and use the results to answer question 11
Visual Deficits

From the Merck Manual,18th Ed., p. 922,edited by

Mark H.Beers. Copyright 2006 by Merck & Co.,
www.brainconnection.com
Whitehouse Station, NJ. Available at:
www.merck.com/mmpe. Accessed: November 28, 2007
 t for
Item 4 of NIHSS: Facial Palsy Te
i
s
a l P alsy
Fac

 Ask the patient or use pantomime

 “Show me your teeth, raise your eyebrows and close
your eyes tightly”
 Score symmetry of grimace to noxious stimulatio
n in the aphasic or confused patient (tickle each
nasal passage one at a time using a cotton-tippe
d applicator and observe facial movement)
Scoring: Facial Palsy (0-3)
 0 = Normal symmetrical movement
 1 = Minor paralysis: (i.e., flattened nasolabial fold, asym
metry on smiling)
 2 = Partial paralysis (total or near total paralysis of lowe
r face)
 3 = Complete paralysis of one or both sides (absence of
facial movement in the upper and lower face)
 Note:
 Aphasic or confused patient: Score symmetry of grimace to noxi
ous stimulation
Facial Palsy in Stroke

www.stroke.org.uk
Item 7 of NIHSS: Limb Ataxia
“Finger-Nose-Finger” & “Heel to Shin”
for
Test
L
UL/L ion
o o rdinat
C
Item 7: Limb Ataxia
“Finger-Nose-Finger” & “Heel to Shin”
 Finger-Nose-Finger: The examiner raises their finger mid
line, 2 ft from the patient
 Patient is asked, “With your right hand, touch my finger, then to
uch your nose; do this as fast as you can.” Repeat with the oth
er arm.
 Heel to Shin: Pt can be lying on their back or sitting
 Ask pt to slide one heel down shin of the opposite leg, then repe
at the same procedure on the other side
 Dysmetria: the inability to accurately control the range o
f movement in muscle action with the resultant overshoo
ting of the mark
Item 7: Limb Ataxia
 Detects unilateral cerebellar lesion & limb movement abn
ormalities in relation to sensory or motor dysfunction
 Use “finger-nose-finger” and “heel to shin” tests
 Test non-paretic side first
 Look for smooth, accurate movements
 Consider limb weakness when looking for dysmetria
 Non verbal cues are permitted
 Test all four limbs separately
Scoring: Limb Ataxia (0-2, X)
 0 = Absent
 1 = Present in one limb
 2 = Present in two limbs
 Note:
 Ataxia is only scored if present. In patient who can’t u
nderstand the exam or who is paralyzed, a score of 0
(absent) is given
 If patient has mild ataxia and you cannot be certain t
hat it is out of proportion to demonstrated weakness,
give a score of 0
 Medical Management of S
Thrombolytic
treatment:
troke
recombinant
tissue
plasminogen
activators (r-
tPA)

Craniotomy
& clot
evacuation
+/- shunting
(for relieving
intracranial
pressure), if
clot size is
very large
Other Potential Operations targeting specific p
athology for Hemorrhagic Stroke

Atrial Fibrillation
& Ischemic Stroke
5. In case the clots are
passed to cerebrovascular
circulation and get stuck
there, it cause STROKE
4. The clots may be
dislodged and passed into
ciculation

Left Atrial Appendage

(A common site where thrombus is formed)

1. Abnormal automaticity
of atrial non-pacemaker
myocardial cells

2. Inefficient contraction of
the Atrium and also in-
synchrony beating with
the ventricle causing
some of the blood being
stagnant in the atrium

3. Stagnant blood begins

to clot.

Left atrial appendage is a

common site where blood
clots form
 Common Medications used among Stroke
Patients
Improve Prognosis Relieve Symptoms

Old vs. New generation

e.g. Aspirin,
Clopidogrel (PlavixR)
e.g. Metoprolol
(Betaloc)
e.g. Simavstatin
Angiotensin-Converting
(Zocor)
Enzyme (ACE) inhibitors

e.g. Lisinopril (Zestril) e.g. Valsartan (Diovan)

Angiotensin II Receptor
Blockers
e.g. Isosorbide dinitrate
(Isoket)
e.g. Amlodipine
(Norvasc)

e.g. Frusemide
(Lasix)

e.g. Amiodarone
Old vs. New generation
e.g. warfarin,
dabigatran

Digoxin 
“Blood Thinners” or Anti-Clotting Drugs
(for prevention of thrombosis and/or stroke)
1
Vitamin K Antagonist, e.g. Warfarin
versus
2
Anticoagulants Non-Vitamin K Antagonist Oral Anticoagulants (NOACs)
a) Direct Thrombin Inhibitor, e.g. Dabigatran etexilate
b) Factor Xa Inhibitors, e.g. Apixaban, Edoxaban, Rivaroxaban

Sometimes, using both “Clopidogrel + Aspirin” together would be

Antiplatelet termed DAPT – Dual Antiplatelet Therapy
2. Chronic Subdural Hematoma
(CSDH)
 • A short news pub
lished in METRO
on 5/9/2019 by D
R. Dawson, a ne
urosurgeon as w
ell as a close part
ner of Occupatio
nal Therapy
– DR. FONG used
to work in various
settings, e.g. QE
Surgical intervention H, TMH, QMH
– Burr hole
• Clinical Course
– Often insidious –
being recognized
only when sympt
oms become maj
or & lead to accid
ents / disabilities
– “Chronic” = more
than 2 weeks
 Major Symptoms
• Three “I”s; usually descri
bed by Geriatricians
1) Immobility (Balance / Gait
disorders) – leading to rep
eated falls when injuries N
OT detected
2) Intellectual impairment (im
paired conscious level, con
fusion, other impairment in
cognitive functions, …)
3) Incontinence ( - not neces
sary a MUST; but occasion
al)
• Other symptoms – vomit
ing, headache, etc.

Kolias, AG et al.(2014) Chronic subdural haematoma:

modern management and emerging therapies Nat. Rev.
Neurol.10, pp 570–78
 Glasgow
Max. 4 Coma Sc
ale
Max. 5

L evel o f
or
Test f iousness
c
Max. 6 Cons
1. Other chronic conditions (esp. …
neurological diseases – CSHD)
2. Cognitive impairment …
3. Balance or gait impairment …
… predisposing factors for
FALL

Tinetti ME & Kumar C (2010)

Care of the Aging Patient: The
Patient Who Falls “It’s Always a
Trade-off” JAMA; 303(3): pp 258-
66
 Med
Mgt.
Kolias, AG et al.
(2014) Chronic
subdural
haematoma: modern
management and
emerging therapies
Nat. Rev. Neurol.10,
pp 570–78
Rehabilitation
• Can start after the
removal of drainage –
usually have FU CTB
x review
• Prognosis depending
on
1. chronicity,
2. functional status before
surgical/medical
management, and,
3. promptness /
effectiveness of surgical
intervention

• A high percentage
may have residual
disabilities – long term
support from carers
+/- community support
services
3. Parkinson’s Disease
 Parkinson’s Disease
Parkinson’s Disease (primary or idiopathic) versus
Parkinsonism (or secondary)
Parkinson’s disease (PD) is a
degenerative, progressive
disorder that affects nerve
cells in deep parts of the
brain called the basal ganglia
and the substantia nigra.

Nerve cells in the substantia

nigra produce the
neurotransmitter dopamine
and are responsible for
relaying messages that plan
and control body movement.

For reasons not yet

understood, the dopamine-
producing nerve cells of the
substantia nigra begin to die
off in some individuals. When
80 percent of dopamine is
lost, PD symptoms such as
tremor, slowness of
movement, stiffness, and
balance problems occur.
 Initial Stage

Resting tremor (characterized

by “pill rolling” in some pt.)

Mid-Stage
On-Off
Phenomenon
** Bradykinesia **, i.e. slowness
in initiation of movements
Rigidity
(characterized by
“cog-wheel” rigidity
in some pt.) Balance Problem

Advanced & Debilitating Stage

Neuro-cognitive Dysfunction
Sinemet & Madopar are two common ones for PD
Deep Brain Stimulation

刺激器費用相
當昂貴，大約
十五萬至二十
萬港元（由
2012 年中始，
通過相關評估
的病人，醫院
管理局會全數
資助刺激器及
電極等硬件的
費用）
II. Cardiac Conditions
(esp. ACS & CHF)
 Types of Cardiac Conditions being
introduced
1. * Valvular Disorders (the doors cannot close or open properly)
 Aorta stenosis
 Mitral valve stenosis | Mitral valve regurgitation
2. Inflammatory Disorders (inflammation / infection)
 Endocarditis | Myocarditis | Pericarditis)
3. Arrhythmias (conduction problems)
 Tachy. >>> AFib, Ventricular Tachycardia (VT), VFib
 Bardy. >>> SSS, AV or Heart Block (1st, 2nd, 3rd deg.)
4. * Coronary Artery Disease (blockage of blood supply to
cardiac muscle)
 Acute >>> Acute Coronary Syndrome (ST elevated MI | non-ST
elevated MI | Unstable Angina)
 Chronic >>> Chronic Stable Angina
5. * Congestive Heart Failure (impaired filling / pumping function)
 CHF (with reduced EF or Systolic HF vs. with preserved EF or
Diastolic HF)
Common Symptoms of Cardiac Conditions

Angina Dyspnea
Shortness of Breath Orthopnea Peripheral Edema

Fluctuating
Blood Pressure
Palpitation

Fatigue

Sometimes –
Syncope NO Observable
Symptoms
4. Common Valvular Disorders
 I. Structure of the Heart
Four Chambers & Four Valves
Bicuspid
Tricuspid
(mitral)
valve
valve
Aorta
Superior vena cava
Pulmonary arteries

Right atrium Left atrium

Left ventricle
Right ventricle

Inferior vena cava

Pulmonary
semilunar Aortic
valve semilunar
valve
What would happen when there are Da
mage | Disease of the Valve(s)
The valves of the heart open
and close like doors, allowi
ng blood to flow through to
the heart and lungs.

When a heart valve is diseas

ed or damaged, it does not a
llow blood to flow properly.

 Stenosis 瓣 膜 狹 窄
 Valves don’t open properly
 This reduces the pumping abil
ity of the heart to push blood
through the valve to your bod
y
 Regurgitation 瓣 膜 反 流
 Valves don’t close properly
 Blood would leak backwards; t
his makes the heart work hard
er to circulate the blood
Common Valvular Open Close

Disorders Normal

Stenosis
Open Close
Aortic Stenosis
主動脈瓣膜狹窄

Mitral Valve
Stenosis
二尖瓣膜狹窄 Regurgitation
Open Close

Mitral Valve
Regurgitation
二尖瓣膜反流
The Opening & Closing functions of these valves
(doors) may not be 100% perfect in most people. It
may NOT require any treatment as long as there is no
limiting symptoms.
However, there may be incidents of rapid
deterioration when
• being exposed to infection(s)
• there are other co-existing cardiac conditions
 Causes of Valvular
Diseases
(A) Rheumatic
Heart Disease
(B) Degenerative 風濕性心臟病
Calcification
鈣化老化

(C) Endocarditis
感 染 性 心 內 膜 炎 
(D) Congenital Valve
Disease
先天性心臟瓣膜異常
 Presentation & Symptoms of
Valvular Disorders
• Abnormal sound (Heart Murmur)

• Fatigue

• Shortness of breath, particularly

when you have been very active or
when you lie down

• Lower limb odema

• Dizziness

• Syncope

• Irregular heartbeat
 Diagnosis of Valvular Disorders
 Echocardiography. 
 In this test, sound waves directed
at your heart from a transducer
held on chest
 Produce 2D fan-shape video
images of heart in motion.
 Assesses different structure of
heart, the heart valves and the
blood flow through the heart. 

 Electrocardiogram (ECG). 
 Chest X-ray. 
 Cardiac MRI. 
 Stress tests. 
 Treatment of Valvular Disorder
 Medication (if symptoms mild)
 Diuretics
 Digoxin

 Surgical options
 Heart valve repair
 Replace cords, cut excessive
tissue etc…
 Percutaneous balloon
valvuloplasty
Mechanical valve
瓣膜氣球擴張術
Porcine heterograft
 Heart valve replacement valve
 Surgical replacement
 Transcatheter (e.g. TAVR)
 + Anticoagulation therapy
 1st 3-6 months post-operation
 May life-long for mechanical valve
 Treatment of Aortic Valve Disorder
(Cont’d)
 Transcatheter Aortic Valve Replacement
(TAVR)
 a relatively new procedure that delivers a replacement
valve in much the same way that a cardiac stent is
implanted
5. Acute Coronary Syndromes
 Common Conditions associated wi
th Coronary Artery Disease (CA
D)
不穩定性心 非 ST 段 上 升 型 ST 段 上 升 型
絞痛 心肌梗塞 心肌梗塞

Impact of atherosclerosis Stable Angina ** Acute Coronary Syndrome (ACS) **

on blood flow
穩定性心絞 急性冠狀動脈綜合症
 Symptoms & Diagnosis CAD
Symptoms
 Chest pain (angina); may radiate to
neck, jaw and arm pain
 Crushing pressure on chest
 Shortness of breath (SOB)
 Fainting
Diagnostic Tests
 ECG (at rest or when performing exercise
“Stress Test”)
 Blood test(s) for
 Cardiac enzymes – bio-marker of cardiac injury /
death of myocardial cells
 Risk factors, e.g. blood lipids, blood sugar, etc.
 (COROnary) Angiogram or Cardiac
Catheterization
 direct observation of blood flow and
blockage under X-ray, after a special dye is
passed through the catheter
 Others
 MRI, CT scan
 Echocardiogram
Investigation and Management of ACS
 Specific Shape(s) suggesting
Ischemia Change & Myocardial Infarction
 Serum Cardiac Biomarkers

Troponin I
H

… interpreted in conjunction with

Diagnostic cutoff value for AMI clinical / imaging / ECG findings.
is 0.50 ng/mL.
 Percutaneous Coronary
Intervention (PCI)
via radial artery in the wrist
orvia femoral artery in the groin

4. The tip of the catheter is

moved into the narrowed
section of the artery.

Primary Percutaneous Coronary Intervention (pPCI) refers to the strategy of

taking a patient who presents with STEMI directly to the cardiac catheterization
laboratory to undergo mechanical revascularization using balloon angioplasty, coronary 5. As the balloon is blown
stents and other measures. up the stent opens up 6. The balloon is let down and
inside the artery the tube is removed.
The stent is left in place to keep
 Percutaneous Transluminal Coronary Angioplasty (PTCA)
+/- Stent

Bare Metal Stent

(BMS)

Drug Eluting Stent

(DES)

Bioresorbable Vascular Scaffold

(BVS)
Dual Antiplatelet Therapy (DAPT)

DAPT
(Dual Antiplatelet Therapy),
i.e.
Aspirin
+
Any one new generation antiplatelet [P2Y 12 receptor
antagonists], e.g. Clopidogrel, Prasugrel, Ticagrelor.
From 1 month to 12 months
藥
力
生
效
時
間
 Coronary Artery Bypass Graft
冠狀動脈繞道
>50% blockage
of Left Coronary
Artery (LCA)

Triple Vessel Disease

Internal Mammary Artery

(From chest)

Saphenous Vein
(From leg)

Traditional: using a heart-lung machine & the heart is stopped

while the surgeon completes the operation
Off-Pump: No heart-lung machine is used
6. Congestive Heart Failure
 Signs & Symptoms of Heart Failure
Dry, Hacking Cough

Shortness of Breath

Symptoms getting worse

Swelling (Odema) of or new symptoms during
LOWER BODY, including legs, Acute Exacerbation
feet, ankles, and even abdomen.

Sudden weight gain >3 lbs

within day(s) (due to odema)

Trouble Sleeping (or even

Orthopnea)

Mild Symptoms when

condition is stable

Other Adverse symptoms

American Heart Association H
eart Failure Stages
• Stage A:
– Presence of heart failure risk factors
but no heart disease and no sympto
ms
• Stage B:
– Heart disease is present but there ar
e no symptoms (structural changes i
n heart before symptoms occur)
• Stage C:
– Structural heart disease is present A
ND symptoms have occurred
• Stage D:
– Presence of advanced heart disease
with continued heart failure symptom
s requiring aggressive medical thera
py

Yancy, C. W., et. al. “2013 ACCF/AHA Guideline for the Management of
Heart Failure: A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice
Guidelines.” Circulation 128.16
 Types of Heart Failure
 HF with reduced ejection fraction (HFrEF), i.e. LVEF≤40%
OR, systolic failure
 the left ventricle loses its ability to contract normally (become too weak)
>> the heart can't pump with enough force to push enough blood into
circulation
 HF with preserved ejection fraction (HFpEF), i.e. LVEF>50%
OR, diastolic failure
 the left ventricle loses its ability to relax normally (become too stiff) >>
the heart can't properly fill with blood during the resting period between
each beat.
Impairment usually first identified for the
left ventricle and then gradually involved
right ventricle.

If the alteration in the structure and

function of the right ventricle (RV) of the
heart is caused by a primary disorder of
the respiratory system, this form of
RIGHT VENTRICLE failure is named as
Cor pulmonale.
 Investigation &
Diagnosis Heart
Failure

Cardiomegaly: cardiac-to-thoracic width

ratio above 50 percent

(Potential)
Pulmonary
vascular
congestion

Blood Test for B-type natriuretic peptide (BNP)

 a natriuretic hormone released primarily from the heart, particularly the ventricles
 Useful in distinguishing Heart Failure (HF) from other causes of dyspnea - Most dyspneic
patients with HF have values above 400 pg/mL.
Cardiac Resynchronization Therapy
同步雙室起搏器
 Common Medications for Management of
Cardiac Conditions
Improve Prognosis Relieve Symptoms

Old vs. New generation

e.g. Aspirin,
Clopidogrel (PlavixR)
e.g. Metoprolol
(Betaloc)
e.g. Simavstatin
Angiotensin-Converting
(Zocor)
Enzyme (ACE) inhibitors

e.g. Lisinopril (Zestril) e.g. Valsartan (Diovan)

Angiotensin II Receptor
Blockers
e.g. Isosorbide dinitrate
(Isoket)
e.g. Amlodipine
(Norvasc)

e.g. Frusemide
(Lasix)

e.g. Amiodarone
Old vs. New generation
e.g. warfarin,
dabigatran

Digoxin 
 Types of Cardiac Procedures commonly seen

1. Cardiac Catheterization Procedures

 Percutaneous Balloon Valvuloplasty for correcting stenosis, e.g.
PBAV (Percutaneous Balloon Aortic Valvuloplasty), PBMV
(Percutaneous Balloon Mitral Valvuloplasty), … etc.
 Transcatheter Aortic Valve Replacement (TAVR)
 Radiofrequency Ablation for correcting tachyarrhythmia(s)
 Percutaneous Transluminal Coronary Angioplasty (PTCA)** +/-
stent(s) for revascularization of coronary circulation
2. Open Heart Procedures
 Repair of heart values
 Replacement of heart valve, e.g. SAVR (Surgical Aortic Valve
Replacement)
 Coronary Artery Bypass Graft (CABG)**
 Heart Transplantation

Extended anticoagulation or antiplatelet may be required following the

procedures in order to minimize complications and improve prognosis.
 Common Implantable Electronic Devices

Pacemaker Cardiac Resynchronization Implantable Cardioverter

心臟起搏器 Therapy (CRT) Defibrillators (ICD)
心臟再同步化治療 植 入 式 去 顫 器 

Provide appropriate heart Correct inter- / intra- ventricular Prevent sudden cardiac death:
rate, correct bradycardia dyssynchrony (i.e. ventricle anti-tachycardia pacing,
1. Single chamber contraction not in sync) for cardioversion, defibrillations,
2. Dual chamber patients with HFrEF, wide QRS & pacing for patients with VT &
3. Biventricular LBBB history of VF (or cardiac arrest)
2nd Prevention & Rehabilitation – IMPORTANT to OT
TARGETS ? HOW ?

Smoking Cessation
|--------------------- Risk Factors ---------------------|

Macro Level
How service is
organized &
delivered –
Service Models

Micro Level
Physical Activities What are the
• Preferably daily – or at least Not

•
less than 3 times per week
Not less than 30 min each time
Knowledge &
Skills required on
our Health Care &
Rehabilitation
Workers
Stress
• Optimization – NOT affecting
rest & daily life
 III. Pulmonary Conditions
(esp. COPD, Respiratory Failure, Pneumoni
a)
7. Chronic Obstructive Pulmonar
y Diseases (COPD)
Related Diseases of COPD
 COPD: Definition & Overview
1 5
6

4
Mechanism Leading to Airflow Ob
structions 2

3. Airway 1. Alveolar
lumen may attachments
be occluded may have
by mucous reduced
secretions elasticity and
become
disrupted as
a result of
emphysema

2. Thickening Barnes PJ New England Journal of

of airway wall Medicine. 2004;350(26):2635-7.

due to
inflammatory
changes
Airflow Limitation – based on 2

Spirometric Values
• FVC (forced vital capacity):
– maximum volume of air that can be exhaled during a forced maneuver.

• FEV1 (forced expired volume in one second):

– volume expired in the first second of maximal expiration after a maximal i
nspiration, which is a measure of how quickly the lungs can be emptied.

• FEV1/FVC: (<0.7 >>> airflow limitation)

– FEV1 expressed as a percentage of the FVC, gives a clinically useful ind
ex of airflow limitation.

Obstruction Restriction
Another Spirometric Tracing –
Flow Volume Loop
• Standard on most Desk-Top spirometers
– Adds more information than volume time curve
– Better at demonstrating mild airflow obstruction

• X-axis:
– the air volume in liters
• Y-axis:
– the flow rate in liters per second
• Expiration results
– Plotted above the horizontal axis
• Inspiration results (if “Ins
piration Maneuver” is co
nducted)
– Plotted below the horizontal axis
Airflow Limitation2 is closed linked with Air
Trapping & Hyperinflation in COPD

i.e. larger End Expiration

Lung Volume

Barrow chest
Flattened diaphragm
 Dynamic Hyperinflation
Static Dynamic
Decreased IC
Normal Hyperinflation Hyperinflation
IRV

IC
TLC

VT
ERV
FRC

RV
Air trapping at rest Air trapping from
Years - Decades exertion
Seconds - Minutes
 Making Diagnosis for COPD

Airflow
Limitation
Cardinal
signs &
+
symptoms Signs &
Symptoms
+
“Chronic” Exposure
refers to > History
3 weeks

=
COPD
History

(GOLD, 2009)
 Commonly Used Inhalers
Category Drug name Brand name
Beta2 -agonist
• Short-Acting (SABA) • Salbutamol • Ventolin®
• Long-Acting (LABA) • Indacaterol • Onbrez®
• Olodaterol • Striverdi®

Anticholinergics
• Short-Acting (SAMA) • Ipratropium bromide • Atrovent®

• Long-Acting (LAMA) • Tiotropium • Spiriva®/Respimat®

• Glycopyrronium bromide • Seebri®

• Vilanterol / Umeclidinium • Anoro®

LABA + LAMA • Indacaterol / Glycopyrronium • Ultibro®

Inhaled Corticosteriods • Beclazone • Becotide®

(ICS) • Becomethasone • Becloforte®
• Formoterol / budesonide • Symbicort ®/ Vannair®

• Formoterol / Fluticasone • Flutiform®

LABA + ICS
• Salmeterol / Fluticasone • Seretide®

• Vilanterol / Fluticasone • Relvar®

Anticholinergic = Antimuscarinic (almost interchangeably)

 Different Devices
Metered Dose
Inhaler (MDI)

Handihaler
Soft mist

Volumatic-type
Spacer
Breezhaler

Ellipta Genuair
Accuhaler
Aerochamber

Holding
Chambers
Turbohaler
 Acute Exacerbations4 of COPD
• Definition
– an acute change in dyspnea, cough and/or sputum sufficient eno
ugh to warrant therapy change1
• Symptom
– At least two of:
• increase in SOB,
• sputum purulence,
• sputum volume
– Or any one above and one of: URTI, Wheeze, Cough, Increase i
n resp. / pulse rate
• Epidemiology
– In a 12-month observational study (n=127), 77% of patients repo
rted having at least one exacerbation2*
1. American Thoracic Society/European Respiratory Society. Standards for the diagnosis and management of patients with COPD
[Internet]. Version 1.2. www.thoracic.org/go/copd. Accessed April 30, 2008.
2. Anthonisen et al Ann Intern Med 1987
3. O’Reilly, et al. Prim Care Respir J. 2006;15:346-353.
 COPD Assessment
Test (CAT)

CAT Score Impact

Cough
> 30 Very High
Sputum
> 20 High
Chest Tightness
10 – 20 Medium
Activity Limitation - Stairs
< 10 Low

Activity Limitation – in Home

Online Test
Activity Limitation – Going Out

Sleep
Common Medical Management
of AECOPD
• Oxygen therapy
– maintain the saturation of arterial blood at > 90%.
• Short-acting inhaled beta2-agonists, with or without short-acting
anticholinergics
– Nebulised bronchodilators are often given during the period of distressed breathing
• Systemic corticosteroids
– Duration of therapy should not be more than 5-7 days.
• Antibiotics
– Despite viruses and pollutants being implicated in many exacerbations of COPD, an
tibiotics are still widely used.
– most effective in severe exacerbations with increased sputum volume and purulen
ce.
– amoxicillin is usually the first choice.
– Duration of therapy should be 5-7 days.
• Aminophylline (Controversial due to side effects)
– sometimes being used when no response to SABA
8. Respiratory Failure
 Respiratory Failure
Respiratory failure
• failure of the lungs to function properly. The main tasks of
the lungs and chest are
– to get oxygen from the air that is inhaled into the bloodstream (the
n the level of oxygen in the blood becomes dangerously low), and
,
– at the same to time, to eliminate carbon dioxide (CO2) from the blo
od through air that is breathed out (then, the level of CO2 become
s dangerously high)
• Usually a response to AECOPD
• Type I Respiratory failure:
– Low PaO2 without increased in PaCO2 (i.e. no CO2 retention)
• Type II Respiratory failure:
– Low PaO2 with increased in PaCO2 (i.e. with CO2 retention)
Chronic Respiratory Failure
• the condition remained despite after optimal medical treat
ment
 What is ABG?
• Arterial Blood Gas (ABG) Analysis is used to measure the followi
ng components of an arterial blood sample
– Partial pressures of Oxygen (PaO2),
– Arterial Oxygen Saturation(SaO2)
– Partial pressures of Carbon Dioxide (PaCO 2),
– pH, and,
– Bicarbonate (HCO3-)
• ABG can help identify and monitor
– Respiratory Failure (Type I vs. Type II), i.e. PaO2
– Ventilatory Failure (or Pump Failure), i.e.  PaCO2
– Acid-Base In-balance (Acidosis vs. Alkalosis) >> When pH outside the ran
ges, there would be cell deaths
• ABG facilitate the decision to implement and/or terminate Rx.
– Oxygen Therapy
– Non-Invasive Ventilation (NIV)
 6 Easy Steps to ABG Analysis

1. 1. Is the pH normal? (Acidosis/ Alkalosis)

2. 1. Is the pCO2 normal?

Respiratory/ Metabolic
3. 1. Is the HCO3 normal?

4. Match the pCO2 or the HCO3 with the pH

1. Does the pCO2 or the HCO3 go to the opposite direction of the

5. pH? (Compensatory?)

6. 1. Are the pO2 and the O2 saturation normal? (Hypoxemia?)

 Arterial Blood Gas (ABG)
Parameters Test Value Normal Reference Comment
pH 7.27 7.35 – 7.45 acidotic
pCO2 53 35 – 45 mmHg acidotic
pO2 50 80 – 100 mmHg low
O2 Saturation 79% 95 – 100% low
HCO3- 24 22 – 26 mEq normal
Step 1: The pH is less than 7.35, therefore is acidotic
Step 2: The pCO2 is greater than, and is therefore acidotic
Step 3: The HCO3 is normal
Step 4: The CO2 matches the pH, because they are both acidotic. Therefore
the imbalance is respiratory acidosis. It is acidotic because the pH is acidotic, it
is respiratory because the CO2 matches the pH
Step 5: The HCO3 is normal, therefore there is no compensation. If the HCO3
is alkalotic (opposite direction), then compensation would be present.
Step 6: Lastly, the PaO2 and O2 sat are low indicating hypoxemia
Impression: Uncompensated respiratory acidosis with hypoxemia >> the patient
has an acute respiratory disorder.
 Indications for NIPPV
(Non-Invasive Positive Pressure Ventilation)
• At least one of the following:
– Respiratory acidosis (PaCO2 > 6.0 kPa or 45 mmHg and arterial
pH < 7.35)
– Server dyspnea with clinical signs suggestive of respiratory mus
cle fatigue, increased work of breathing, or both, such as use of r
espiratory accessory muscles, paradoxical motion of abdomen,
or retraction of the intercostal spaces
– Persistent hypoxemia despite supplemental oxygen therapy
• Goal
– Provide ventilatory support, i.e,
• reduction in respiratory rate,
• increase in tidal volume, and
• reduction in work of breathing
– For
• a reduction in hypercapnia.
• improvement in oxygenation
• decrease in dyspnea
 Steps in Setting Up NIPPV
Choosing an Interface Monitoring Effectiveness

Recheck arterial blood gases

within 2 hours after
application of NIPPV
Facial Complete Helmet Review failure of
Mask Facial Mask
improvement in blood gases
or signs of respiratory failure,
From e.g.
Ward 1. Severe leakage around
the mask
To 2. Inadequate FiO2, IPAP
Home Oral-Nasal or EPAP
(if Hypercapnia continued) Nasal Mask Mask 3. Copious respiratory
secretion with difficulty in
Prescribing Settings clearance
IPAP/EPAP settings Bi-Level Positive Airway Pressure (BiPAP)
machines
Back up respiratory rate IPAP (Inspiratory Positive Airway Pressure /
Inhalation Pressure)
FIO2, if necessary EPAP (Expiratory Positive Airway Pressure /
Spontaneous / Time mode or Assist-control mode Exhalation Pressure)
 1
Home Oxygen System
For continuous use (if needed) at home
Stationary Oxygen Concentrator

Intensity 8L Nuvo 8L Integra 10L HomeFill

System
For outdoor activities or as back-up during electrical / failure of the stationary
oxygen concentrator

Portable oxygen Oxygen cylinder

concentrators with or without
Conserving Device
 Definition of Home Oxygen Therapy
• Usually a low flow oxygen system for use by patients with
chronic conditions e.g. COPD using at HOME or residenti
al settings.
• Sometimes being called “Domiciliary Oxygen”
• Low flow system
– flow rates less than the patient’s inspiratory demand & not for sup
porting life as in acute situations, i.e. the delivered oxygen is dilute
d with room air (usually through nasal cannula)
• High flow system
– flow rates high enough to completely satisfy the patient’s inspirator
y demand by entrainment of ambient air or by a high flow of gas,
e.g. Venturi mask
• The usual O2 Delivery System is Oxygen Concentrator
 Key Terminology
(Related to “Patient Indications” & “Goals of Therapy”)

Short Term Long Term

Palliative
Oxygen Therapy Oxygen Therapy
Oxygen Therapy
(STOT) (STOT)

Ambulatory /
Continuous Use Nocturnal Use
Exertional Use

(Related to daily usage; hours of therapy, associated daily activities)

 Terms about Daily Usage

• Long term continuous

Continuous
administration of oxygen for at
oxygen therapy
least 15 hours a day

• The provision of oxygen therapy

Ambulatory
during exercise and activities of
oxygen therapy
daily living

Nocturnal • The provision of oxygen therapy

oxygen therapy during sleep / daytime nap
 Terms about Indications & Goals
LTOT
Patient Indications COPD patients with
chronic hypoxaemia, i.e.
PaO2 is consistently at or
below 7.3 kPa when
breathing air during a
period of clinical stability.
Goal Improve survival
Assessment
Timing of When Clinical stability is
Assessment defined as the absence of
exacerbation of chronic
lung disease for the
previous five weeks.”
ABG (RA) Mandatory for those
Continuous
Assessment for EID Mandatory
Overnight Oximetry Mandatory if indicated
Implications a lifetime commitment
STOT Palliative
Any Patients, including For non-hypoxemic patients
COPD, who, at the time of who use oxygen therapy
discharge from hospital, and, solely for symptomatic relief
demonstrate i) consistent of intractable
desaturation, ii) reliance breathlessness
on oxygen therapy unresponsive to all other
modalities of treatment
Maintain oxygenation while Relieve symptoms
recovering from acute conditions
varied varied
Not mandatory Not mandatory
Mandatory Not mandatory
Preferred if indicated Not mandatory
Require comprehensive Based on clincial needs
reviews after receiving Home
Oxygen Therapy for 1-3
months
 Clinical Assessments for hypoxaemia:
Blood gas  related lab. result, or
Desaturation Test, or
Overnight oximetry  sleep study

For patients with various chronic diseases, COPD patients or Not supported by evidence for home oxygen
Documented NO terminal diseases with intractable dyspnea, who therapy & is not recommended .
oxygen report improvement in symptoms, function and quality of life
desaturation?
 
  On occasion considered by specialist teams if
intractable dyspnea is unresponsive to all other
YES
treatment modalities

For patients suffering malignancy or terminal diseases with

Malignancy or YES intractable dyspnea, who
terminal report improvement in symptoms, function and quality of life
disease? Palliative
Palliative
Oxygen
OxygenTherapy
Therapy
NO
For patients with various chronic diseases, or COPD patients,
Regime: Varies, according to individual
who
Clinically stable NO needs
demonstrate oxygen desaturation or a reliance on oxygen
during Ax?
therapy at the time of hospital discharge, and not being
  optimally treated.

YES
Stable chronic hypoxaemia

Long Term Short Term

Long Term Short Term
Oxygen Therapy Oxygen Therapy
Review for Dose Oxygen Therapy Oxygen Therapy Review for Re-
Titration in 6-12 certification between 1 &
3 months
months
 
For COPD patients,: For COPD patients, who: For COPD patients, who:
whose hypoxaemia, i.e. ≤ 7.3kPa (or 55mmHg), or in the range 7.4-  have oxygen desaturation in exertion to have oxygen desaturation to SpO2 88% as illustrated in
7.9kPa (or 56-59mmHg) together with hypoxia-related SpO2 88% in desaturation test, and overnight oximetry or sleep study, and
consequences such as cor pulmonale, pulmonary hypertension, demonstrate full compliance to the trial use of the therapy,
 demonstrate full compliance to the trial use
secondary polycythaemia with haematocrit >56%) are and improvement in symptoms and quality of life.
ascertained based on repeated ABG, and of the therapy, and report improvement in Further assessment required for patients complicated with
who should have received optimal medical treatment, especially symptoms, function and quality of life.  sleep-related breathing disorders
after episodes of acute exacerbation
   

Continuous Ambulatory/Exertional Nocturnal

Continuous Ambulatory/Exertional  Nocturnal
Use Use Use
Use Use Use
Regime: Use >15 hours per day, including sleep Regime: Use only for specific daily activities that caused Regime: Use only for sleep
desaturation
9. Pneuomonia
Pneumonia is an infection that inflames the air sacs in one or
both lungs. The air sacs may fill with fluid or pus (purulent
material), causing cough with phlegm or pus, fever, chills, and
difficulty breathing. A variety of organisms, including bacteria,
viruses and fungi, can cause pneumonia.
 Microorganisms may be
differ for different living
settings of the sick elderly
 1) Age-related
Alterations in
Immune Function
Next slide
2) Impact of
Comorbidity on
Next slide Immune Function

3) Impact of
Malnutrition on
Immune Function
+ … reduction in ADL

Altered presentations of
pneumonia in the elderly as
compared to younger age
group
 Pneumonia can induce a
much higher mortality rate
among the elderly
compared with young adult
“C/ST” = Culture & Sensitivity
– for identification of specific
microorganism and selection
of the right antibiotics

Exploration for potential

“Aspiration Pneumonia”
Special Considerations for Occupational Therapists
1. Prevent, monitor and treat hospital acquired complications and
associated disability
2. Prepare care-givers on discharge from hospital esp. for elderly
who have a significant change in functional levels
3. Liaise for post-discharge service(s): medical, rehabilitation, social
“Sepsis”, a common complication following
infection, e.g. pneumonia among the elderly
and can be life-threatening.
II. Orthopedic Conditions
(esp. ACS & CHF)
10. Colle’s Fracture
Colle’s Fracture
 An Example of Treatment Algorithm of Extra-articular Distal Redial Fracture

POP
Or
Dynacast
 11. Hip Fracture(s)
(including Femoral Neck Fractures, Intertroc
hanteric Fractures & Subtrochanteric Femur
Factures)
 Hip Fracture(s)
a) Femoral Neck b) Inter-trochanteric
Fractures Fractures

c) Sub-trochanteric
Femur Factures
Closed or Open Reduction + Internal Fixation in order to allow early mobilization
& better pain relief
Conservative Treatment limited to those not fit for surgery
 Biomechanics of Fixation
• Stress Sharing Device
• Permits partial transmission of load across the fracture site
• Micromotion at the fracture site induce secondary bone healing with callus f
ormation
• E.g. cast, rods, intramedullary nails.
• Stress-Shielding Device
• Shields the fracture site from stress by transferring stress to the device
• Fractured ends of the bone are held under compression and there is no moti
on at the fracture site >> primary bone healing
• E.g. compressing plate
 Weight Bearing
1. WBAT for stable impacted # or endo-protheses
a) Femoral Neck Fracture(s) 2. NWT to PWB for unstable # that require reduction in the 1 st 6 wks

Cannulated
Expected Time of Bone Healing Screw fixation
• 12 to 16 weeks
Expected Time of Rehabilitation
• 15 to 30 weeks

Dynamic Hip
Screw fixation
Hip Range Precautions (i.e. avoid PROM, IR & ADD past midline)
1. Limited to those with arthroplasty done, esp. in the 1 st 4
weeks
2. Guarded use gradually
Hemi-arthoplasty: replace femoral head only, e.g.
• Thompson (cemented – claimed less post operative pain)
• Austin More (Uncemented)

Total Hip replacement: replace both femoral head & acetabulum

• Thompson (cemented – claimed less post operative pain)
• Usually for younger & active cases
 Seinsheimer Orthopedic Trauma Association
Classification x (OTA) Classification x
Subtrochanter Intertronchanteric

Plate
Angled Blade
Gamma Nail

(PFNA)
Dynamic Hip
Screw fixation

Nail Anti-rotation
Proximal Femoral
Garden stage I : undisplaced incomplete, including valgus
impacted fractures.
Garden stage II : undisplaced complete
Garden stage III : complete fracture, incompletely
displaced
Garden stage IV : complete fracture, completely displaced

AO/ASIF classification for trochanteric femoral fractures:

A1 fractures are stable pertrochanteric fractures
A2 fractures are unstable pertrochanteric fractures
Type I: Up to 308. The compressive forces are
with medial comminution including a fractured
predominant.
minor trochanter
Type II: 30–508. The shearing stress is present and
A3 fractures are unstable intertrochanteric fractures with
may have a negative effect on the bone healing.
or without medial comminution, including the reversed
Type III: 508 and more. The shearing stress dominates
intertrochanteric fractures and transverse
and is associated with a significant varus force. This
intertrochanteric fractures, with possible dorsolateral
results in fracture displacement and varus collapse.
comminution.

e.g. THR e.g. AMA / Thomson e.g. cannulated screw e.g. DHS e.g. Gamma Nail / PFNA
12. Cervical Myelopathy
 Terms
• Cervical Spondylosis • Cervical myelopathy (Cervical Spondylotic Myelop
– a general term for age-related athy
wear and tear affecting the spi – a loss of function in your upper and lower extremities beca
nal disks in your neck. As the d use of compression of the spinal cord within your neck. Ce
isks dehydrate and shrink, sign rvical myelopathy can involve your arms, hands, legs, and
s of osteoarthritis develop, incl bowel and bladder function.
uding bony projections along t
he edges of bones (bone spur
• Cervical radiculopathy
s) – often called a "pinched nerve," occurs when a nerve in you
– also being called cervical oste r neck is compressed or irritated where it branches away fr
oarthritis om your spinal cord. This can cause pain that radiates into
your shoulder, as well as muscle weakness and numbness
• Stenosis that travels down your arm and into your hand.
– As a result of the degeneration
of discs and other cartilage, sp
urs or abnormal growths called
osteophytes may form on the b
ones in the neck. These abnor
mal growths can cause narrowi
ng of the interior of the spinal c
olumn or in the openings wher
e spinal nerves exit, a related c
ondition called cervical spinal s
tenosis.
• Japanese Orthopedic Assoc
iation JOA score
 Surgery
• Indications
– Surgery is usually recommended only for moderate, severe or any progressive disea
se.
– Or when the concerned patients suffer a fall accident resulting in further spinal injury
– Patients with mild CSM can be offered rehabilitation therapy first. If there is no impro
vement, surgery may be offered.
• Purpose
– Decompression (e.g. laminectomy, …) +/- Stabilization, if indicated (e.g. spinal fusion
& fixation)
 Neck Collars for Cervical Spine Injury
at different levels

Soft Neck Collar Philadelphia Neck Collar SOMI Brace Halo jacket for high
(Sternal Occipital level cervical injury
Mandibular Immobilizer)

Increasing degree of stability

Duration of Use: ranged from 8 – 12 weeks (sometimes even longer)