April/May 2000

Increasing Independence

By Gretchen Renee Schmelz, MHS, OTR/L

Splints, assistive equipmentment, and occupational therapy help patients maximize their self-feeding skills-a key element to achieving autonomy.

Self-feeding is defined as “fulfilling sociological and psychological needs” of the individual.1 When the development of prerequisite skills for self-feeding is arrested and the individual is no longer able to feed herself, dependency, low self-esteem, and depression may ensue.

The rehabilitation team’s responsibility is to provide a comprehensive program that enables and promotes the maximal level of independence in activities of daily living (ADLs). Occupational therapists explore many treatment approaches in conjunction with the multidisciplinary team physician, nurse, physical therapist, and speech-language pathologist. Decisions are made for the best treatment paradigm.

Self-Feeding Approaches

Occupational therapists need to evaluate sensory-motor, visual-perceptual, and cognitive components involved in self-feeding before determining a treatment approach. Sensory-motor is a complex area to examine. Delving into the motor skills necessary to perform ADLs is the first step. Muscle strength, muscle tone, and coordination of the upper extremity will influence the patient’s ability to manipulate a spoon, cut the food into smaller pieces, and scoop the food onto the spoon. When a patient is lacking strength in deltoids, biceps, supinator, wrist extensor, and finger flexors, the act of bringing the hand to the mouth becomes a difficult task.

Many people experience changes in muscle tone after damage to the brain or spinal cord from disease or accidents. When the muscles are very tight (hypertonicity) or very floppy (hypotonicity), the task of bringing the hand to the mouth or maintaining appropriate sitting posture is arduous. Muscle coordination is also valuable so the patient can aim the spoon/fork toward the food and directly up to the mouth. If the hand/arms are shaking (tremors), the patient will exert strenuous effort just to reach the mouth with the food still on the spoon.

Integration of the sensory system is vital in order for the patient to tolerate the texture of the food/utensil on his hand. Without the sense of body position in space—proprioception—the patient is not able to move the hand to the mouth accurately. Constant feedback is given to the individual on where the hand is in relation to the mouth. This enables the patient to bring the hand to the mouth instead of the ear.

The integration of the vestibular system provides information to the patient on how to adjust the head in relation to the upper body without tipping over. The vestibular system works closely with vision, the higher system. Together the integration of vision and vestibular systems promotes appropriate body position for self-feeding and movement of the eyes to guide the hand to the utensil. The occupational therapist utilizes the sensory integration theory developed by Jean Ayres to evaluate sensory integration in relation to self-feeding on a constant basis.

Vision is an integral component of sensory integration; it can impact the ability to feed significantly. Visual, perceptual, and motor skills are continuously evaluated during ADLs by the occupational therapist. Figure ground (the ability to distinguish foreground from background), visual acuity, visual fixation, and visually scanning the environment are all skills necessary to locate food, utensils, and the table. Some individuals who experience a cerebral vascular accident (CVA) may actually have a field cut and/or neglect. They may neglect half of the plate without realizing the mistake.

The volitional drive to self-sustain is considered a basic drive. However, when some individuals experience a CVA, traumatic brain injury, or debilitating disease, psychological and cognitive issues undermine their ability to continue this basic task. The patient may lack sufficient attention span, problem-solving skills, or memory to perform feeding.

After a thorough evaluation and consultation with the rehabilitation team, including the patient, the treatment begins. Occupational therapists may incorporate several treatment paradigms. The biomechanical, neurodevelopmental, and rehabilitation/compensatory approaches are noted for self-feeding therapy techniques. Implementing the use of the mobile arm splint (MAS), fabrication/training with custom splints/orthoses, providing functional neuromuscular electrical stimulation to weakened hand/arm muscle, and devising custom self-feeding systems are important.

Splints

The mobile arm splint has been called the balanced forearm orthosis or a ballbearing feeder.2 The MAS is mounted on the wheelchair and assists the patient to self-feed with slight motions of the trunk and shoulder complex.

Yasuda et al conducted a study of the successful outcomes of MAS in ADLs with 29 subjects who had degenerating muscular disease.3 The outcome measure was based on “speed of performance in self-feeding combined with the reported frequency of daily use.”3 The researchers found that the “major motivation for MAS use” was self-feeding. Even when the individual lacks strength in elbow/wrist/finger flexion/extension, the orthosis can be utilized to incorporate the remaining skills that the individual possesses to improve independence in ADLs.

A case report on a 20-year-old woman with Rett syndrome illustrated the successful utilization of a wrist/finger splint designed and implemented by an occupational therapist.4 According to Sharpe and Ottenbacher, “The syndrome, which only affects females, is characterized by apparently normal development during the first 6 to 18 months of life, followed by developmental regression, loss of purposeful hand use, appearance of stereotyped hand washing movements, deceleration of head growth, gait apraxia and jerky truncal ataxia, autistic-like behaviors, and severe mental retardation.”5 The therapist designed the self-feeding protocol by observing inherent physical needs and interests of the patient. Inquires were made on the patient’s muscle tone, muscle patterns, habits, current abilities, and skills/hobbies. The occupational therapist fabricated dorsal wrist splints, splints that give a stable wrist pattern and functional hand placement for feeding. Soon the client was able to bring a spoon toward her face.

The assistive equipment included a deltoid suspension sling to aid in shoulder/elbow movement, a scoop dish designed to increase scooping ability by raising the side of the dish, and an angled built-up spoon to accommodate limited grip and movement of forearm/wrist. After careful considerations, the splints were revised. An opponens component, which aided in the abduction of the thumb, a more functional position of the hand, and a stabilizing device (volar finger gutter splints) for finger joint stability were added to the splint. The patient could now bring her spoon to her mouth 50% of the time and return to her plate 40% of the time independently. The theme continues to “fit the patient, not to fit the adaptive equipment.”1

Modalities

Occupational therapists are able to use a variety of tools to increase self-feeding by fully understanding the person involved and building on his or her capabilities, not disabilities. Another tool OTs are beginning to familiarize themselves with in order to increase independence in ADLs is functional neuromuscular electrical stimulation (FNMES). FNMES allows the therapist to promote motor learning of appropriate muscle patterns for functional activities and increase voluntary muscle strength.

Other modalities often utilized before FNMES in order to increase muscle strength/control include vibration, taping, and short-term icing applied to the muscle belly. The electrical stimulation is a facilatory device applied to the muscle to improve functional use of the upper extremity. In the study by Carroll and Meeny, electrical stimulation was implemented to restore self-feeding in a patient with quadriplegia.6 According to the investigators, “The patient’s primary goal was to be independent in self-feeding and it was hoped that his motor recovery would be sufficient to enable him to achieve this goal.”6 Initially, assistive equipment was implemented along with the FNMES. A deltoid assistant sling was utilized due to the patient’s limited shoulder movement.

A wrist cock-up splint to aid in wrist extension and a palmar pocket with modified spoon were helpful in aiding the patient. FNMES was performed for an extended time to the deltoid muscle (shoulder). The patient was able to place a spoon into his mouth independently with support for wrist and palmar position by the end of the research project. Not only does the spinal cord injury (SCI) population benefit from FNMES, patients who experienced a CVA have increased independence in feeding after receiving therapy with electrical stimulation.

A study by Francisco et al focused on the use of electrical stimulation on wrist extensors—extensor carpi radialis longus and brevis.7 The nine subjects were within 6 weeks of a CVA and randomly assigned to a electrical stimulation or control group. The electrical stimulation group participated in two 30-minute sessions per day for strengthening wrist muscles. The functional outcome measure was determined by 10 occupational therapists. The therapists ranked the self-care items by using the functional independent measures. Of the six items addressed, self-feeding was the most likely to be enhanced by electrical stimulation. The other areas included grooming, upper/lower body dressing, bathing, and toileting. With the increase in the elderly population and in dependency on health care, technology is being developed to improve the quality of life for people with special needs.

Robotic Devices

As the aging process occurs, the ability to perform self-care diminishes; however, occupational therapists continue to make strides to improve quality and quantity of life by enhancing self-care skills with assistive devices. Throughout the literature robotics are being considered to aid in self-feeding. For example, the Handy One, a device originally designed to assist a child with cerebral palsy to eat without the care of an attendant, has made dramatic improvements in the effectiveness of self-feeding.8

The Handy One has a scanning system of lights that covers the tray and allows the user to select food from any part of the plate. Food is arranged in “walled three columns and a series of lights begin to scan from left to right behind the food dish.”8 Once the light is behind the column of food desired by the individual, the user presses a single switch that enacts the Handy One to scoop the food from the dish. The food is presented to the individual at the desired speed and position. A computer assists in tracking where the food may be located on the dish and scans past the empty columns. The clients that utilized the Handy One enjoyed the freedom to socialize with family members while eating independently with the robot’s aid.

Three models of powered feeding devices were compared by Hermann et al.9 Handy One was one of the feeders; the Beeson feeder and the Winsford feeder were the additional self-feeding robotic devices. The Beeson feeder utilizes pneumatic switches and is driven by an electrical motor. The two switches control the movement of a pie plate and the action of the spoon. The Winsford feeder utilizes a mechanical device that pushes a spoon and an arm that pivots to raise the utensil to the individual’s mouth. The device has two switches. The first switch provides availability of the plate by performing a complete circle. The food is then pushed onto the spoon and the spoon is presented to the user. The study consisted of 12 subjects.

The cost of robotic devices varies widely. The return gained from the devices must be emphasized with further research and training. This will justify to insurance companies the savings in time and cost of paying a technician, which will outweigh the up-front cost. A study by Bach et al demonstrated that by using commercially available training robot manipulators, patients with advanced Duchenne muscular dystrophy could increase independence in ADLs.10 After modifications were made to industrial robot manipulator training devices, patients with only slight finger movements were able to operate these devices. In fact, the devices were shown to reduce the amount of the health care technician’s time each day by 3 hours. During the study, occupational therapists provided the introductory training and remaining training occurred at home for about 2 weeks. This included controlling the functions and programming of the devices. The three areas of self-care included “eating, manipulation of remote and environmental control devices, and recreational activities.”10

Various studies have been conducted on self-feeding devices; for example, one study illustrated the development of a robotic arm worktable system for people with SCI. According to Seamone and Schmeisser, “fast moving microprocessor technology leading to low-cost, highly capable microcomputer systems has been a key technical element in a research program aimed at examining the practicality of using a robot arm to assist the physically handicapped.”11 The program identified self-feeding as one of the most important basic needs of people with SCI using the robotic arm. Other uses include management of reading material, use of telephone/typewriter, grooming, and vocational needs. As the study progressed, adaptations were made in the arrangement of the plate and design of the spoon. The robotic arm had a program designed to rotate the plate automatically and pick up small portions of food with the spoon. The spoon was brought to the client’s mouth and then the utensil was dropped so a napkin could be brought to the mouth. The project was a success as indicated by the seven out of nine people with quadriplegia who “found the equipment gratifying to use, especially for self-feeding.”11

Fabricating Feeding Devices

Obviously, from the results of several studies, robotic feeding devices are effective in promoting self-feeding. However, when financial resources are not available, a custom feeding device can be fabricated. Hon Keung Yuen developed a device to enable a client with closed head injury (CHI) to perform the task more independently. The effects of the CHI made it difficult to hold a utensil in the customary way. The patient had spastic hemiparesis in the right arm and ataxia in the left arm, and could not negotiate the fine/gross motor task of manipulating a spoon with either hand. After a thorough assessment was conducted on motor/range of motion capabilities, the OT performed a self-feeding and a neuropsychological evaluation. The patient had difficulty with short-term memory, visuospatial functions, and low frustration tolerance. Therefore, the device would have to create a simple way to gain access to the food, utilizing a different mode rather than the hands/arms.

While observing the client performing a craft with a mouth stick, the OT determined a new mode for self-feeding. After numerous trials with different designs, the OT was able to use inductive reasoning to determine the best device fitted to the patient, not fitting the device to the patient.1 The spoon was wrapped with metal and had a plastic measuring cup for the handle. The holder for the spoon contained two magnets that were fastened to a wooden block mounted on top of a dowel. The spoon was placed on top of the magnet at the same height of the user’s face. The client would scoop up the food with the spoon in his mouth and then place the spoon on top of the magnetic holder. Then the patient would take the food off the spoon with his tongue/lips. The device was successful by eliminating the need for an assistant after the system was set up. The patient improved by eating more, increasing socialization during meal times, and gaining independence in self-care tasks. The device cost less than $50 to make and saved the facility substantial money by reducing staff time.

An important theme throughout the available research is that the “opportunity to perform self-care is an important a contributor to these tasks as the ability to perform.”12 In other words, the rehabilitation team, especially the OT, must ascertain the individual’s strengths and capabilities before designing and implementing a self-feeding program. Another important theme is the need for further research studies to be conducted on the effectiveness of sensory integration therapy in producing self-organization, resulting in improved capability to self-feed. The most crucial studies appear to be current with the factors affecting the health care arena today. These outcome studies determine fiscal results of using self-feeding devices. When it has been proven that they reduce staff time and improve independence in self-care, self-feeding devices will become commonplace instead of an anomaly.

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