2. Activities of daily living (ADL) are tasks of
self-maintenance, mobility , communication
and home management that enables an
individual to achieve personal independence
in his or her environment.
The purpose of an ADL program is to train the
patient to optimally perform, within the
limit of his physical disabilities, all activities
inherent to his daily life.
3. Activities of daily living are usually taught in
the following manner:
1. Any given activity is broken down into its
simplest components.
2. Patient performs these specific motions, in
the form of graded exercises.
3. This activity itself is practiced in a real
life situation.
4. The role of exercise therapy is, after all, to
improve the patients ADL.
Therefore, therapy programs are so designed
as to restore or maintain range of motion and to
develop strength and co-ordination.
The different exercises learnt are incorporated
into useful activities in real life situations. For
example, exercises to improve range of
movement of the shoulder can help in reaching
out for objects placed above his head, or wash
himself during his toilet.
Strengthening his grip is later useful to shave
himself, eat food or handle crutches.
5. ADLs are grouped according to various areas
of activity in the day to day life of the
patient.
Residual disability, skills acquired, job, home
plan, and office designs are all taken into
consideration while grouping ADL’s.
Obviously,all activities need not apply to any
one patient.
In rural India, the challenges are more,
since self help aids are not available; neither
has technology penetrated to that level.
6. Daily activities are classified as:
Bedside activities
Wheelchair activities
Self care activities
Miscellaneous hand activities
Ambulation
Elevation
Traveling
Management of environment control
devices
Communication
7. Activity Grading
The extent to which the activity can be
performed is graded as,
• Independent in performing the activity
• Needs assistance to do so
• Needs to be lifted to perform the activity
• Dependent—activity cannot be performed by
the patient
• Activity contra indicated, as it may be
harmful to the patient or those around
him, like driving a public vehicle.
8. Barthel’s Index of Activities of Daily Living (BAI)
The patient is assessed according to his or her status in the
following daily activities and based on whether he is
dependent or independent, given a score from 0 to 3:
• Bowel status (0-2)
• Bladder status (0-2)
• Grooming (0-1)
• Toilet use (0-2)
• Feeding (0-2)
• Transfer (0-3)
• Mobility (0-3)
• Dressing (0-2)
• Stairs (0-2) and
• Bathing (0-1)
9. There is also a Modified Barthel score which further
increases the sensitivity of the score ranging from 0
to a maximum possible 100 without increasing
difficulty of undertaking test or time involved, and
with scores from 0-5 in individual tasks.
Functional Independence Measures (FIM)
A broad based measurement of function, which is
used by several rehabilitation centers, is the
Functional Independence Measure (FIM), a chart that
consists of 18 categories of function (sub grouped
under self-care, mobility,locomotion, sphincter
control, communication, and social cognition), each
scored on a scale from 1 (dependent) to 7
(independent). Overall scores may range from 18
(totally dependent) to 126 (totally independent).
10. These include all gross body motions necessary
to move about in bed, position, rolling over,
moving to the sitting position, and sitting
up.After coming to sit, the patient must
maintain sitting balance while moving trunk
and arms in all directions.
He/she must be able to cover himself with
bedsheets, reach out to the side table and
manipulate objects (like ringing a bell
or attending to the telephone).
Eating food and toileting are also bedside
activities, which need to be trained. Patients
with quadriparesis and muscular dystrophy are
often evaluated for bedside ADL.
11. Wheelchair Activities
Very often people have to spend their lives in
a wheelchair. They have to be taught how to
select their wheelchair, and then trained in:
• Wheelchair transfers to bed, chair,
bathtub, or toilet.
• Wheelchair management—handling parts,
propulsion, steering, and negotiating
obstacles, and maneuvering in and out of
rooms.
• Maintenance of the wheelchair parts.
12. Personal Care
• Self care activities
– Personal hygiene (e.g. bathing, cleaning teeth, combing
hair etc)
– Personal image (care of hair and nails, use of makeup,
shaving)
– Attending to toilet needs (bedpan, urinal)
Dressing activities/undressing:various modifications to
the
dresses, like Velcro fastening instead of buttons may
also be made to facilitate easy wearing and removing.
• Eating activities: the patient is given exercises to
improve hand functions so that he can eat on his own.
Modifications of spoons and forks may have to be done.
13. Miscellaneous Hand Activities
• Handling the telephone, signal buttons,
coins, etc.
• Using spectacles, watch, lights, etc. while
sitting reclining and other positions.
• Fine motor skills, like writing, cutting
vegetables.
14. Ambulation and Elevation
The patient is evaluated on
• Gait patterns within the home or out of
doors on different ground surfaces.
• Help to stand up and sit down from various
heights.
• Need for Locomotor aids.
• Ability to negotiate staircases and kerbs.
15. Traveling
He should be able to drive and maintain a
two wheeler or car, use the garage,and
practice to get in and out of the vehicle.
The vehicle itself can be modified to
accommodate his wheelchair.
Public transport in several countries is
modified to enable senior citizens to step on
and off buses or trains.
The entire bus level is lowered so that the
passenger can embark or disembark.
16. Environmental Control System (ECS)
Environmental Control System is defined as a
means to control and interact with the
environment by switching on and off devices
through switches or voice activation, by remote
control.
The purpose of the ECS is to maximize functional
ability and independence in the home,
school,work and leisure environment.
An ECS basically consists of the following:
An input method via single, dual or multiple
switches. The selection may
be direct or through a method of scanning
various target devices.
17. A control or signaling device to change input into
infrared pulses,ultrasound, voice or radio
frequencies.
• These input signals are received by a device
which activates the target,computer.
• A target device that responds to the signals
relayed.
• The connection or interface between the
signaling devices and the target device.
• Output or feedback mechanism to inform the
user of the results and actions.Some are simple
systems that control two or three appliances like
the fans and lights; others are more complex and
can control several appliances simultaneously.
18. Devices that can be Controlled by an ECS
Telephone
TV
Electric bed
Lights
VCR
Window opener
Call bell
Stereo Drapes/curtains
Alarm systems
Compact disc player
20. The importance of communicating to ones fellow
human beings cannot be underscored enough.
Every person needs to transmit his or her
feelings and thoughts and today’s modern
technology comes to ones aid while doing so.
Communication includes the ability to write,
operate a personal computer, read,type or use
the telephone, a tape recorder, or a special
communication device.
Several devices are used by the Person with
Disability to keep in touch with the outside
world.
21. The patient is evaluated as dependent,
assisted dependent or independent in his
ability to transfer himself to and from tub or
shower stool, bed, toilet, chair, wheelchair
and car.
He is also evaluated for balance in various
activities from which he can perform his
ADL’s.
The occupational therapist fills out a chart,
as given below to indicate the ADL status of
the patient and follows through with the
progress.
22. Eating/Drinking Remarks (dependent, assisted
dependent or independent)
Mix rice, idli with spoon/hand
Cut meat/chapati
Eat with hand/spoon
Eat with fork
Drink with straw
Drink from glass/cup
Pour from vessel
23. Undressing and Dressing
Dates Remarks
Pants or shirts
Banian
Underwear
Blouse or shirt
Brassieres
Underskirt
Sari
Night clothes
House coat
30. Operate
Dates Remarks
Light switches
Door bell
Door locks and handles
Faucets/Taps
Washing machine
Remote control device
The above chart is only indicative and would
vary according to the culture,nationality and
personal taste and lifestyle of the patient.
31. The hospital environment is very much different
from the home.
Very often a situation arises when a locomotor
aid or device is prescribed or given away,only to
find out later that it is of no use to the patient
in his home.
A rehabilitation center ideally should have a
‘stay in home’ simulating the patients
environment so that the transition from center
to home is smooth.
Therefore it is essential that the physiatrist and
therapist perform a visit to the patient’s home,
preferably together.
The patient and a family member should be
interviewed to determine their expectations.
32. In India, where the joint family system is still
prevalent in some areas and family bonding is
still taken for granted, the patient tends to be
looked after with great and sometimes excessive
care by the family members.
Though it can’t be denied that family is
paramount in the rehabilitation of the
individual, this leads to a situation when the
patient depends on his family to take care of
him for everything, even simple activities of
daily living that he can do.
Motivating such a patient to take care of himself
is a challenge.
33. The occupational therapist should estimate
which ADLs are possible and which are
impossible for the patient to achieve. He should
explore the use of alternate methods of
performing the activities and the use of assistive
devices.
In order to motivate the patient the objectives
are framed with a short and long-term
perspective
• The training program may be graded by
beginning with a few simple tasks and gradually
increasing their number and complexity.
34. The methods of teaching the patient to
perform daily living tasks must be tailored to
suit each patient’s learning style and ability.
• Patients who have perceptual problems, poor
memory, and difficulty following instructions
of any kind will require a more concrete,
step by step approach which is easy to
comprehend.
35. Before beginning training in any ADL the
therapist must begin by providing adequate
space and arrange equipment and furniture
for convenience and
safety.
• Architectural barriers must be removed at
home and office. Performance is modified
and corrected as needed and the process is
repeated to ensure skilled performance
36. Upper Limb Dressing:
• The neck has to be stable on the shoulder girdle
• The muscle strength in the upper limb should be
3/5 to 4/5.
• The range of movement at the shoulder must be
at least 0-90 degree of flexion/abduction, 0-30
degree of medial or lateral rotation, and 15-140
degree elbow flexion.
• Sitting balance without support in bed and
wheelchair Ability to use buttons or fasteners. A
flexor hinge hand splint may be used if the
patient has good wrist extensor power.
37. Lower Limb Dressing: The trainer, usually a
physiotherapist enhances the muscle strength
and ensures the extent of movement at the knee
and hip that must permit the person to sit with
legs fully stretched and reach out to his calf.
Generally a range of 0-120 degrees would be
adequate.
Body control, such as ability to transfer from
bed to wheelchair with minimum assistance
rolling from side to side, or balance when lying
on side, must be developed.
If patient has spasms and can control them, they
are used to his advantage to flex and extend the
lower limb.
38. Clothing should be loose and have front
fastenings.
• Zippers or Velcro fasteners are preferred to
buttons.
• Since patients often use the thumb to fasten
zippers, loops are recommended.
• Shoes should be carefully selected so as to
provide foot stability during patient transfer.
• Personal preference is given a lot of
importance and the rehab professional must
have a ‘What can I do for you’ instead of a ‘I
think you must have this’ approach.
39. Adaptations:
• A brush with grip is used for bathing or
shampooing hair.
• A bath brush is provided with a long handle to
reach behind the back
• A position-adjustable hair dryer.
• A long handled toothbrush, lipstick applier or
razor.
• A short reacher Dressing sticks to enable the
person to pull on clothes.
• The bathtub can have safety rails, and
extended or built up handles on faucets
40. “When you cannot change the patient,
change the environment”.
If a patient with rheumatoid arthritis
repeatedly comes to the department saying
that she cannot the tap, it is far easier to
change the tap than to keep strengthening
her grip.
41. A vast array of adaptations are improvised to
keep pace with the revolution in
communication
• Adaptations to the computer and keyboard
• Telephones should be placed within easy
reach. A clip type receiver, a
dialing stick or push button phone may make
usage of the phone easier.
• Built up pens and pencils with an easier grip
42. Store frequently used items on the lower
shelves of the cabinet. Sit on a high stool to
work comfortably. Use a reacher to get items
beyond your reach.
Stabilize mixing bowls and dishes or
vegetables with some aid. Use lightweight
utensils, and where possible and safe use
powered can openers and mixers.
Use long handled taps and a top loading
automatic washer and an adjustable ironing
board.
43. The general health condition (apart from the
disability), like respiratory infection, cardiac
problems or diabetes which can inhibit ADL
training, are regularly monitored.
Daily checks must be carried out for pressure
sores.
The patient may not be co-operative to the
idea of dressing even if in the presence of a
professional.
44. Any pain in neck or trunk that persists when
attempting training can interfere with
activities of daily living.
Affordability is another question, with most
of the population in India unable to even buy
a good wheelchair, let alone sophisticated
items like an environment control system or
a motorized wheelchair.
45. Animals have been giving companionship to
man since time immemorial.
The relationship between dog and master,
over the ages borders on almost complete
dependence and understanding.
They provide a loving comforting presence,
which is unconditional, and undemanding.
Such trained are used in institutions for
lonely and depressed patients to alleviate
boredom, give affection and help in their
activities of daily living
46. . They are used along with treatment sessions
with physical, occupational and speech
therapists, and also for petty jobs like
bringing in the paper.
It is also possible to involve animals in goal
oriented activities.
For example
To achieve tone inhibition and improved
coordination, we can throw objects for the
animal to retrieve, or use hand signals to
communicate to it.
