The Indian Journal of Occupational Therapy : Vol. XXXIV: No. 3
ACTIVITIES OF DAILY LIVING (ADL) ASSESSMENT A measure for grading 'activity limitation' in Leprosy patients Nandgaonkar Hemant P., Mancheril Joy, Ebenezer J., Samy A.A. Alert India - Mumbai.
INTRODUCTION Discussing the outcome measures in peripheral neuropathies, Molenear et al. stated "We believe that impairment measures give information on the biological effect of treatment, whereas disability and handicap measures give clinically important and patient relevant information showing whether a treatment improves the patient's functional health."1 Leprosy cured persons with deformity or disabilities look forward to a "normal" day-to-day living. It is a known fact that "misuse" and "disuse" of insensitive and paralytic limbs are the main cause for deterioration of deformities and disabilities. The study examines the relationship between the Activities of Daily Living and the type and severity of deformity in leprosy patient. to assess the severity of the impairment in a given individual and to monitor the success of prevention and treatment of impairment requires an appropriate impairment measure. At the same time, measures to assess Activities of Daily Living and relevant social participation for the people affected by leprosy should be developed. In leprosy, physical rehabilitation efforts have mainly centered on prevention and treatment of primary and secondary impairments. Despite preventive efforts in the management of leprosy a high proportion of patients are still presenting with nerve damage, with consequent deformities and increased risk of ulcer formation or other complications. If prevention of impairment and disability (POID) is the principle aim then impairment and disability should be distinguished. Also making a patient appropriately independent instead of dependent or inappropriately independent should be the target. Considering these factors, the Activities of Daily Living evaluation scale was devised with new type of scoring system, which stressed upon the evaluation of harmful ways of doing Activities of Daily Living. It was an interview-based assessment of Activities of Daily Living.
OBJECTIVES
4. To find out which is the most affected area of Activities of Daily Living and needs intervention.
METHODOLOGY A revised version of the I.C.I.D.H. (International Classification of Impairment, Disability and Handicap) was introduced in 1997-the I.C.I.D.H.-2. In this revised classification, the terms"disability" and "handicap" were replaced by the more intuitive and positive terms 'activities (of daily living) limitation' and social 'participation restriction'. According to these definitions, the well-known WHO Disability grading scale does not grade disabilities but impairments. Hence, we refer to the WHO disability grade as the "WHO impairment grade."1 Specifically the study examines 209 leprosy patients with Grade-II deformities on the basis of International Classification of Impairments, Activities and Participation (I.C.I.D.H.-II-WHO1997). (APPENDIX-I). The severity of impairment was determined by applying the WHO deformity grade to each of the limbs and eyes and the scores are summed up. Activities of Daily Living evaluation was divided into three areas-self care, work and leisure. Each of this sub-area was further represented by number of activities applicable to the patient. Work area was subdivided into home making tasks, meal preparation and service and work habits and attitudes. Work habits and attitudes were in turn represented by number of work characteristics like standing for long time,heavy lifting, handling sharp tools safely, strenuous eye activities etc. Leisure was similarly subdivided into hobbies and habits, spiritual activities, 2,3,4 While scoring, we had taken into consideration the independent and dependent aspect of an Activities of Daily Living activity, since it is the fact that it was a part of preventive rehabilitation. For this reason the scoring was further divided into appropriate ways of doing activities and inappropriate ways of doing activities, i.e. to say whether it is appropriately independent or inappropriately independent (APPENDIX-2).
1. To find out the Activities of Daily Living status in leprosy patients with disabilities and deformities.
Further to determine the socio-economic status Kuppuswamy's socio-economic scale'urban' was applied.5,6 The data required to determine socio economic status was:
2. To adopt the new type of scoring for Activities of Daily Living evaluation in leprosy patients.
1) education- professional degree, graduation, H.S.C., S.S.C., illiterate etc,
3. To find out correlation between WHO disability grade and Activities of Daily Living evaluation scale.
2) occupation-professional, skilled worker, unskilled worker, unemployed etc,
Correspondence : Dr. Nandgaonkar Hemant P. (O.T.) 20, Pushpanjali, Goshala Road, Mulund (West), Mumbai - 400 080. E-Mail:
[email protected] Phone : 022 2561 45 79
3) and family income status- to know the per capita income,
IJOT : Vol. XXXIV : No. 3
with respect to the individual leprosy patients. After collecting this data the socio economic status was represented as middle class, lower middle class, poor & very poor.
Dec.-March 2002-03
RESULTS
Eyes
The 209 patients with deformity WHO grade-II (APPENDIX-5) were selected for Activities Of Daily Living assessment utilizing the above referred scales and definitions to determine their Activities Of Daily Living status.
95% of the patients assessed had no major eye problems due to leprosy (score-0) In all, there were 10 cases with eye problems mainly lagophthalmos. Six patients had only one eye affected (score2); Four patients had lagophthalmos in both eyes (score-4).
TABLE:1
On the bais of the sum total of the scores 44% scored up to 2. 55.5% patients had multiple deformities as they scored between 3 to 8. There was only 1 patient who scored 12. In 9 to 11 scores there were no patients. It is because of most of the deformities were in hands and feet. (APPENDIX-4)
THE AGE AND SEX DISTRIBUTION OF THE RESPONDENTS Male adults Female adults
126
(60%)
76
(37%)
7
(3%)
209
(100%)
Children Total
tTABLE:2 RESULTS OF ACTIVITIES OF DAILY LIVING EVALUATION
Hand
ADL
Mean
Standard Deviation
Mini.
Among the patients studied 21 per cent had no deformity in the hand (score-0); 6 per cent had only loss of sensation (score-1); 50% had one hand involved (score-2); 3% had both hands involved (score3); 20% had grade-II deformities (score-4) in both the hands.
Self Care
93.90
9.73
53
100
Work Area
65.19
15.19
44
100
Leisure
98.43
4.55
75
100
Foot 37% of patients assessed had no foot problems (score-0); 9% had only loss of sensation in one foot (score-1); 26% had one foot involved (score-2); 9% had both foot involved (score-3), and 19% had grade-II Deformities in both foot (score-4).
Maxi.
Above table indicates that,'work area' ADL evaluation was more severely affected than other two areas i.e. 'self-care' and leisure (APPENDIX-4)
TABLE: 3 THE "PROBABILITY VALUES" THE CORRELATION BETWEEN WHO IMPAIRMENT SCORE AND A.D.L. SCORE (PERSON PRODUCT MOMENT CORRELATION COEFFICIENT) Correlations
HAND
FOOT
EYES
SUM
.. (Coefficient)
Self Care
-0.3135
-0.1897
0.0983
-0.2916 (1-tailed
P= 000
P=0.003
P=0.079
P=0.000
significance) (Coefficient)
Work
-0.1686
-0.162
0.0034
-0.2137 (1-tailed
P= 0.007
P=0.010
P=0.481
P=0.001
significance) (Coefficient)
Leisure
0.018
-0.074
-0.0772
-0.0572 (1-tailed
P=0.398
P=0.143
P=0.134
P=0.205
Significance)
The above table indicates that there is significant correlation between the WHO sum score and the individual self care and work area
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Dec.-March 2002-03
score and Activities Of Daily Living sum score. But there is no correlation between leisure and WHO score. As the correlation is negative, there is inverse relationship between the self-care, work area score & Activities Of Daily Living sum score & degree of impairment. This means that as the degree of impairment increases the Activities Of Daily Living Score decreases.
Value
Significance
pearson
28.37
0.00083 (Person chi-square probability)
t-value= -1.43221 Above table indicates that there is significant correlation between types of occupation with ADL work area. More of unskilled and semiskilled workers were affected (61.24% of the studied population).
TABLE: 4 DISTRIBUTION OF WORK LEVEL2 No.
Percent
Sedentary
47
23
Light Work
17
8
Medium Work
82
39
Heavy Work
54
26
9 209
4 100
Very Heavy Work Total
Chi-sqare
TABLE: 6 CORRELATION BETWEEN SOCIOECONOMIC STATUS3 AND WORK AREA SCORE4 Very Severe Middle Class
Above table indicates that 69.37% patient population is engaged in medium, heavy and very heavy work. They face serious sonsequences to their limbs on account of their occupation. As the work Area presents the most serious manifestation of the problem, it is further studied (students 't' test was applied to examine the significance)
Severe Mod.
18
4
30
5
57 27.3%
Lower Middle 24 Class
13
36
5
78 37.3%
Poor and very Poor
31
16
23
4
74 35.41%
73 34.9%
33 89 15.8% 42.6%
Value
Significance
pearson
40.01734
0.00001 (Person chi-square probability)
t-value= -2.12101
CORRELATION BETWEEN TYPE OF OCCUPATION1 AND WORK AREA SCORE2
Unemployed
6
Severe
Mod.
10
30
Most of the population affected in work area belonged to middle class and lower middle class (64.59%).
Mild Row Total 4
TABLE: 7 CORRELATION BETWEEN PRESENT WORK LEVEL AND WORK AREA SCORE5
50 23.9%
Unskilled
29
14
13
4
Very
60 28.7%
Semiskilled
27
5
33
3
Sedentary
11
4
13
3
33
89
34.9%
15.8% 42.6%
1
Kuppuswamy's socio-economic scale'urban'
2
(APPENDIX-4)
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Severe Mod.
Mild Row Total
5
13
3
47 22.5%
4
1
11
1
17 8.1%
Medium Poor
18
19
36
9
82 39.2%
Heavy
18
6
29
1
54 25.8%
7
2
0
0
9 4.3%
Light
31 14.8%
73
Very Severe 26
68 32.5%
Skilled
14 6.7%
Chi-sqare
TABLE: 5
Very Severe
Mild Row Total
14 6.7%
Very Work
73 34.9% 10
33 89 15.8% 42.6%
14 6.7%
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Chi-sqare
Value
Significance
Just, the standardization of Activities Of Daily Living assessment scale will not help the patients in teaching self-care and preventing deterioration of deformities. Because every individual's Activities Of Daily Living varies from the other, depending upon various factors of particular socio-economic context.
pearson
35.21761
0.00043
APPENDIX
(Person chi-square probability)
1.
3. Kuppuswamy's Socio-economic scale 'urban' 4. (Appendix - 4) 5. (Appendix - 5)
The I.C.I.D.H. defines impairment and disability as follows:
t-value= 0.35930
Impairment
The extent to which the work area was affected was directly proportional to the present work level i.e. Medium and heavy worker were involved more in number (65.07%)
Any loss or abnormality of psychological or anatomical structure or function. Disability Any restriction of lack of ability (resulting from impairment), to perform an activity in the manner of within the range considered normal for a human being.
DISCUSSION
Deformity
Most of the patients are" inapproproately independent" for most of their Activities Of Daily Living. After detailed evaluation of Activities Of Daily Living scores, it was found that work area was the mainstay of the inappropriate ways of handling. This is so because doing repetitive nature of the job, standing for long time, working barefoot/hands, sharp tool handling etc. So work area rehabilitation should be the mainstay of concern along with other two areas. This work area may be home making tasks or meal preparation area for women or occupational area for men. Change of occupation is difficult in the urban set up and majority of the patients are unskilled workers. Hence occupation plays an important role in deterioration of deformities.
May be defined as "visible impairment" 2 DEFINITIONS Dependent [Patient is unable to do any part of the activity]
0
Inappropriately independent [Patient is able to complete 1 the activity with/ without difficulty, with may or will lead to reinforcement of abnormal postures or deformity, predispose the body parts for ulcers etc. with such kind of performance of the activity] Appropriately independent [Patient is able to complete the 2 activity with or without adaptive equipment. The way of handling or performing the activity may or will not lead to deforming postures, ulcers or any other complications.]
The reason for this can be viewed in context of social aspect of the disease, loss of sensation and lack of education in taking care of insensitive limbs. Additionally, due to social ostracism they hesitate to ask for help.
3 THE CONDITION OF PATIENTS (209) WITH RESPECT TO EYES, HANDS AND FEET 1. Sum Score in Eye Deformities
Inapproproate intervention with leprosy workers in explaining the process of deformities or the lack of priority for detailed Activities Of Daily Living evaluation also is contributory factors.
No.
Percent
Score-0
199
95
Score-1
0
0
CONCLUSION
Score-2
6
3
The Activities of Daily Living (ADL) and the occupation of the patient are greatly altered the type and gravity of their deformity and disability. Therefore ADL evaluation & intervention should be the regular part of the leprosy treatment. Occupation is the main determinant of the development of secondary deformities. Specifically patients belong to poorer section-specially semiskilled and unskilled workers engaged in heavy jobs. It is the most difficult area of intervention. Often change of occupation is not possible. Hence an individual approach need to be developed in teaching the patients ways and means to protect the limbs while doing their respective occupations.
Score-3
0
0
Score-4
4
2
209
100
Leisure areas are not affected because most of these patients have no special leisure activities.
Total 2. Sum in Hand Deformities
No.
Prevention of Impairment & Disability (POID) cannot be a success without the proper way of handling or doing the Activities Of Daily Living. This can happen only when we find time to study the individual patients Activities Of Daily Living and suggest ways and means to prevent further deformities.
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11
Percent
Score-0
43
21
Score-1
12
6
Score-2
105
50
Score-3
7
3
Score-4
42
20
Total
209
100
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ACKNOWLEDGEMENTS
3. Sum Score in Foot Deformities No.
Percent
Score-0
78
37
Score-1
18
9
Score-2
55
26
Score-3
18
9
Score-4
40
19
Total
209
100
Words have their own handicaps. At no time is this more apparent than when one tries to put in words his feeling of gratitude for those who have helped in a trying venture. This work nevertheless, shall be incomplete, if I don't put or record my heart felt gratitude. It is my pride to express my sincre regards, deep sense of gratitude to my (co-authors) colleagues Mr. Joy Mancheril and Mr. Ebinazer for their invaluable and most needed cooperation and guidance during the period of my studies.
4. Sum Score of Eye, Hand And Foot Score
I would also like to convey my sincere thanks to Mrs. Anthony Samy, Chief Executive ALERT-INDIA, for allowing me to conduct this study in their organization.
No.
Percent
1
0
0
2
92
44
3
26
12.5
4
34
16
5
8
4
6
18
9
I also express my sincere gratitude to Mr.R.C.Sharma for guiding me regarding stattistics of the study.
7
7
3
Last but not the least, I give a million thanks to all leprosy patients.
8
23
11
9
0
0
10
0
0
11
0
0
12
1
0.5
Total
209
I am also thankful to all hardworking community medical workers of ALERT-INDIA for referring me patients, from their respective ones.
REFERENCES 1. Kim H. Van Brakel, Naomi K. Reed (1999), Grading impairments in leprosy. Leprosy Review, 70: 180-188. 2. Helen L. Hopkins, Helen D. Smith (Editors), Willard and Spackman's Occupational Therapy, 8th edition (1993), J.B. Lippincott company.
100
4. CLASSIFICATION FOR ACTIVITIES OF DAILY LIVING SCORING (SEVERITY)
3. Catherine A. Trombly-Occupational Therapy for Physical Dysfunction 3rd edition (1989). Williams and Wilkins.
The following are the categories for determining the level of severity. Mildly Affected
90.01 and above
Moderately Affected
65.01 to 90
Severely Affected
50.01 to 65
Very Severely Affected
50 and less.
4. Pedritti Lorraine Williams-Occupational Therapy - Practice skills for physical dysfunction, 3rd edition (1990). Mosby 5. Mahjabeen Alam, M. Yunus, A. Kalam, A. Khan (1998) study of socioeconomic factors in relation to leprosy. Indian Journal of community Medicine. 23: 2: 77. 6. Mahajan, B.K., Gupta M. Cu-T (1995) Textbook of preventive and social Medicine, 2nd edition, Jaypee.
5. WHO DISABILITY GRADE GRADES
HAND
FOOT
GRADE I
insensitivity
Insensitivity
Conjunctivitis
GRADE II
Ulcer & Injury
Trophic Ulcer
Lagopthalmous
Mobile claw hand
Clawed toes
Iritis/keratitis
Slight absorption
Foot drop
Blurring of vision
Wrist drop
Slight absorption
Severe loss of vision
Stiff joints
Contracture
Blindness
Severe absorption
Severe absorption
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EYE
7. Johnsion Mark V.Keitn Robert Allen, Hinderer Sleven R.(1992). Measurement standards for interdisciplinary medical rehabilitaion. Archives of physical medicine and Rehabilitation - 73: 12-5: 53-523.
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