Raining, it's pouring. The old man is snoring.

Weather. This has been quite a hot topic recently in Malaysia. As you all know, we've been hit with a bad case of haze. It's actually the worse one I've ever seen. These are photo of how it actually looks like from the ferry:



Pretty bad huh? You can't even see the other side, or the ships nearby. So anyway this evening, once of my college juniors (already graduated and works with spinal cord injury clients) asked about standardized assessments to assess our client's capacity in different weather/climate conditions. He pointed out that clients with spinal cord injury at T6 and above are at risk of autonomic dysreflexia (AD) should they be exposed to any noxious stimuli, and also said that weather can affect the performance level of clients with neurological or physical deficits. Our discussion is the inspiration which lead to this post.

I do not know enough about spinal cord injuries to be talking about how weather or climate changes affects AD, so let's look into how weather affects people with COPD. Frankly speaking, weather/climate is a very important aspect when it comes to COPD. While it may indirectly affect the performance of clients with other diseases or dysfunctions, COPD is directly affected by it. COPD clients can be considered a very "selective" group of clients - too hot won't do, and neither would the extreme cold. Well, it's usually same for everyone of us, it's just that instead of shivering or wiping sweat, these people are gasping for breath and fighting to live. There has been many studies on the effect of cold weather on COPD, but little is known about hot weather. Some well-read people are even surprised that the heat can cause exacerbation. Why? My take is that most researches are done in places which snow, hence they usually do not really achieve a high enough level of heat to cause exacerbation. That's why little is known about how heat affects COPD. This is supported by the statistics from SCImago Journal & Country Rank, which shows the top 5 countries that do medical research from 1996 til now are:

1. United States of America
2. United Kingdom
3. Canada
4. Germany
5. Australia

Out of the top 5 countries, 3 of them (which just so happen to be the top 3) are terribly cold (with the exception of southern states of the USA). Coincidentally, many researches on COPD that I've come across are either American or British. However, I did managed to find a report which was written last year about a research on how extreme heat affected COPD. It's conducted by Dr. Meredith McCormack from John Hopkins university. The article can be read here. However, I couldn't find any links to the research paper or abstract. It isn't even listed as her select publications on her profile in the John Hopkins University directory. It's rather tempting for me to contact her and talk about it.

While little research has been done on client's with COPD in the heat, this problem is very real, and affects a lot of people, especially in Malaysia. Many clients complain of feeling short of breath once they walk out of the shopping mall or step out of a car into the extreme heat of a Malaysian afternoon. However, many claim that the effect can be lessened if the increase of heat is gradual. The rainy season is also another factor which can cause the symptoms of COPD to worsen. Rainy weather means higher humidity, which is a no-no for clients, as it can cause mold to form in the client's environment. Clients are also more prone to flu during the rainy season, which ultimately contributes to reduced performance. Haze can affect clients pretty badly as well. Many of them cannot stand the haze, and will feel more out of breath compared to normal. However, I still have not personally seen any readmissions despite the haze (not to mention the chest ward seems surprisingly empty). A colleague suggested that they might have either stayed indoors or might not have made it to the hospital, but I'm hoping it's not the latter.

How is it like to live with COPD?

Identifying signs and symptoms of COPD might seem easy (like it's been more or less summed up in the video above), but identifying deficits in a client's daily lives is not that simple.

Basically, a person's daily live activities are affected by their role in life, cultural background, and lived experiences. Therefore, there is no "one size fits all" intervention in occupational therapy, as client's occupations are considered unique to themselves. Despite that, there are always certain problems that are prominent every COPD client's daily life, and these usually are affected by the signs and symptoms of the disease itself. Here are some more general problems most likely to be faced by people with COPD:

Walking
While walking is not an occupation per se, it can affect many other occupations. Walking is categorized under functional mobility in occupational therapy, meaning it is something we do to allow us to perform occupations. Most people with COPD find it hard to walk long distances, with some of them getting as bad as running out of breath after walking a few metres. It might be hard to imagine, but you can try sprinting as fast as you can for a couple of minutes without stopping to get a feel of how people with COPD feel after they exert themselves too much, which might be just walking for 50 metres.

A client's inability to walk far affects the client in many ways - some of them have problems going out to the shops to buy food to eat, some of them have problems going to the bathroom etc, depending on how far the can walk and what activities they want to do. So while it might seem that walking is a very simple problem, but it can actually make clients lose a big part of their life because they will just be limited to their bed/room/house.

Passing motion
This is one of the less mentioned but very frequently occurring ADL problem that people with COPD face. To be honest, it never occurred to me that passing motion was a problem many COPD clients face until after some time of working in the area. While we may assume that problems in toileting can be linked to them getting short of breath while walking to the toilet, clients have claimed that it's hard for them to pass motion even when they are wheeled to the toilet on wheelchairs, or when they get to the toilet without losing their breath.

The reason is actually linked to constipation - harder faeces cause clients to push harder when passing motion, causing them to go out of breath. The solution is usually pretty easy, increasing their water intake or with the use of enema. But if the client has a secondary condition and cannot take too much water under the doctors advice, and/or if the client does not have enemas at hand (or in cases where enemas can't work), it can be quite a problem.

Eating/Having meals
Not to be mistaken with the OT term feeding, although it is related. This activity is usually a problem for clients who are affected really badly by COPD. While OTs usually assess the feeding function of clients, like bringing the food to mouth (using hands/spoon/chopsticks) or cutting meat and opening bottles*, the physiology of eating (chewing, swallowing etc) also has to be looked into. The tendency of COPD clients to get out of breath often causes them to not be able to eat like normal, as they cannot breath while they eat, so wolfing down food is a big no-no for people with COPD.

Chatting
In this modern age, some people might mistake this for chatting on instant messengers, but no, it's real life chatting or verbal interaction. Chatting does not necessarily have to be done face to face. It can also be done over a phone call too. Many clients with COPD find it hard to talk continuously for a certain period of time, as they cannot talk and breath at the same time.

Other possible areas
While it hasn't been reported, I believe sexual activity could possibly be an activity where clients will face a big problem in. So far I haven't had any clients who has problems in this, particularly because I've never seen any COPD client below the age of 70, and they have been sexually inactive for years. But this could potentially be one area to explore if you have younger or sexually active COPD clients.

There are also certain areas like work (yes, I've had a client who was over 70 years of age and still had to work), hobbies, house chores and other more specific activities that are unique to each client, so digging into the client's life and identifying these occupations** is very important. How do you identify what occupations to look into? That'll come in the next post.

*Cutting meat and opening bottles is listed as the criteria to score a 10 in the Modified Barthel Index.
**As mentioned in the last post, the term occupation here is defined in the OT context, meaning an occupation is an activity that is purposeful and meaningful to the client.

COPD? Is it like LAPD?

Well, no. It's not some police department like LAPD. COPD stands for chronic obstructive pulmonary disease, an obstructive lung disease that over time makes it hard to breathe. It involves inflammation and thickening of the airways, and the destruction of the tissue of the lung where oxygen is exchanged.

This is a short video by Health Guru explaining the mechanics of COPD:

So as an occupational therapist, I'm here to talk about the effects of COPD on an individual - from the lens of an occupational therapists. Basically, occupational therapists focus on the client's ability to engage in occupation, which is defined as purposeful and meaningful activities, as opposed to the layman occupation which means your job title or what you work as. People with COPD will have many problems in their occupations, or rather, as I like to put it (so that non-OTs would understand) - daily living activities*. So what daily living activities do people with COPD face? I'll continue with that on my next post. Stay tuned.

*To occupational therapists, daily living activities, or rather activities of daily living (ADL), is often defined as self care activities like bathing, dressing, feeding etc, and is not associated to hobbies, or what you do at work, or other things you do in life. However, traditionally, ADLs were called BADLs (Basic Activities of Daily Living), therefore the daily living activities or activities of daily living in this blog should not be mistaken for the OT term BADL. When I communicate with other healthcare professionals (usually doctors and specialists), I would always use daily living activities or ADL to describe occupation, as not to confuse them. This is also because they can't seem to grasp the concept of occupation as OTs, do. I do not blame them though - just yesterday I was involved in a discussion in my department about work rehab, where a few OTs defined the term work as OT's definition of occupation, arguing that work rehabilitation also involves to unpaid work (like housewives) or leisure activities, when work rehabilitation program is actually a structured program for employed people on MC to return back to work. This is due to a English to Malay translation problem in the early days, where occupational therapy was called Pemulihan Pekerjaan (Job/Work Rehabilitiation).

Pulmonary Rehabilitation: Where do OTs stand?

Pulmonary rehab is not an everyday field in the world of OT in Malaysia. Although it has been pretty established in countries like UK and Hong Kong, little or almost nothing is known about it in Malaysia. Very often I find myself trying to explain to OTs what our role in pulmonary rehab is. Come on, even the physiatrists in my hospital does not know our role - the housemen of a ward accidentally referred a pulmonary rehab case to the physiatrist and his plan only involved chest physio. Pretty sad when your boss doesn't know what you can do - not that they know much of what we do really (and neither do I know what the purpose of a physiatrist is).

Anyway, without further ado, let's talk about the background of me and the pulmonary rehab program (PRP) I'm currently involved in. I'm a locally trained OT who graduated in 2013. I spent my first year working in neuro rehab, and this is the second field I've worked in. Luckily enough, I joined the chest ward at a very nice time, just as they were kicking off the inpatient pulmonary rehab program for COPD clients. So basically, it's safe to say that I'm the pioneer of pulmonary rehab in my hospital. OTs have been posted to the chest ward in my hospitals for quite some time already, but things weren't so serious in the past. Due to pulmonary rehab not being in our college syllabus, it was a pretty foreign field for OTs who worked in there, and most of the services offered by OTs there were swallowing tests, prescription of compression garments, and ADL and motor retraining for clients with secondary complications. Nothing really focused on chest problems.

Our primary PRP team involves 5 disciplines: physicians, pharmacists, physios and occupational therapists. But due to the lack of man power, it's only 1 specialist, 1 pharmacists, 2 physios and me (the sole OT). Our specialist has also involved other disciplines, like dieticians and psychiatrists (for depression), but they only come in on demand. Then finally, there are also the nurses as well. They usually play the part of ensuring that the client's home program gets carried out, and the right medicine is given at the right time, and other basic nursing care needs. So basically, every Thursday, our specialist will have a pulmonary rehab ward round to discuss the condition of the clients, giving us input on the medical condition of the clients, the pharmacist will give input on the client's MDI technique and other pharmacology stuff, while the physio gives an input of the client's physical condition, like ambulation ability, cough effort etc. And finally, down to us. So what do OTs do?

Just for some suspense, I'll slowly let the roles of OT unfold one by one in future post. The next post would be a brief introduction about COPD, which is the main condition addressed in our PRP.